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DISEASES OE CHILDREN. 



ty'.f 



PRACTICAL TREATISE 




DISEASES OF CHILDREN. 



BY 



f 



J. FORSYTH MEIGS, M.D. 



LECTURER ON THE DISEASES OF CHILDREN IN THE PHILADELPHIA 

MEDICAL ASSOCIATION ; FELLOW OF THE COLLEGE 

OF PHYSICIAN3 OF PHILADELPHIA 




PHILADELPHIA: 
LINDSAY AND BLAKISTON, 

> 1848. 







Entered, according to the Act of Congress, in the year 1848, 

By J. Forsyth Meigs, M.D., 

In the Clerk's Office of the District Court for the Eastern District of 

Pennsylvania. 



SHERMAN, t&l$H£$j 
19 St. James Stfeet. 



TO 

GEOEGE B. WOOD, M.D., 

PRESIDENT OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA, 
PROFESSOR OF MATERIA MEDICA AND PHARMACY 
IN THE UNIVERSITY OF PENNSYLVANIA, 
ONE OF THE PHYSICIANS OF THE PENNSYLVANIA HOSPITAL, ETC. ETC. 

£i)is tt)ork 

IS DEDICATED AS A TRIBUTE OF RESPECT 

FOR HIS HIGH PROFESSIONAL ATTAINMENTS 

AND EMINENT PRIVATE VIRTUES, 

AND AS A MARK OF GRATITUDE FOR HIS VALUABLE INSTRUCTIONS, 

BY HIS FORMER PUPIL, 

J. FORSYTH MEIGS. 



PREFACE. 



The motives which led the author of this volume of the Medical 
Practitioner's and Student's Library, to undertake its preparation, 
were the hope that the details of his own experience might prove 
of some utility, and the belief that a work on the Diseases of 
Children, executed upon a somewhat different plan from those 
already before the profession, might not be an unacceptable addi- 
tion to the medical literature of the country. 

In the preparation of the work no pains have been spared to 
make it both methodical and accurate, and as complete as the 
limits of the series would allow. The classification of diseases 
according to the systems which they affect, has been adopted 
by the writer as the most convenient. The divisions of each 
article are those employed by the most eminent among recent 
systematic writers. In the composition of the work the author 
has availed himself, as fully as possible, of every authority of im- 
portance placed within his reach, always, however, endeavouring to 
judge what came under his notice, by the knowledge derived from 
his personal experience in private practice. In this way he hopes 
that he has been able to select from the labours of others, whatever 
is most important to be known in the present state of medical sci- 
ence, and to reject what seemed fallacious or useless. The work 



PREFACE 



from which he has drawn most largely, is that of MM. Rilliet and 
Barthez, which was originally intended to have formed the basis 
of the present treatise. This plan was, however, abandoned very 
soon after the commencement of the work, from the impossibility, 
with proper justice to those writers, of introducing either the per- 
sonal experience of the author, or a great amount of very useful 
material to be derived from other sources. He desires, however, 
distinctly to acknowledge his great indebtedness for valuable as- 
sistance obtained from their work, especially in regard to the 
symptomatology and morbid anatomy of several diseases brought 
under consideration. 

In addition, the author has constantly consulted the works of 
Underwood, Dewees, Eberle, Stewart, Condie, Billard, Barrier, 
Berton, Bouchut, Brachet, and Valleix, on the diseases of children ; 
the portion of the Bibliotheque du Medecin Praticien, devoted to 
the same subjects ; Tweedie's Library of Practical Medicine, Cop- 
land's Medical Dictionary, the Guide du Medecin Praticien of M. 
Valleix, and the Dictionnaire de Medecine Pratique. Various 
treatises on the practice of medicine, and different articles in the 
medical journals, which it is here unnecessary to mention in de- 
tail, have also been consulted and quoted. 

It is proper to remark in addition, that, in stating what he has 
himself observed, the author has endeavoured to do it with the 
greatest possible accuracy ; and whenever the subject has con- 
cerned facts susceptible of numerical demonstration, he has inva- 
riably, if he has had the means, employed that method of state- 
ment, in order that the reader might be enabled to draw his own 
conclusions. Whatever may be the advantages or disadvantages 
of the numerical method of observation in medicine, it seems to 
him that it must be of vastly greater service in giving accuracy 
and certainty to the recorded results of treatment, than the plan 



PREFACE. XI 

usually followed by the older writers, of merely stating their own 
generalizations (often no doubt loosely and carelessly drawn), in- 
stead of giving to the reader the facts upon which those generali- 
zations were founded, and thus allowing him to judge for himself 
of their probable truth and correctness. 

The author desires to state, in regard to the use of the first 
person singular throughout the work, that, in the words of Dr. G. 
B. Wood upon the same point, he " has been actuated by no spirit 
of egotism, but merely by a wish to express the fact, without affec- 
tation, in the shortest and simplest mode." 

In conclusion, the writer is anxious to express his thanks to 
Dr. Alfred Stille, of this city, for much valuable advice in regard 
to the preparation of the work. 

Philadelphia, June 21, 1848. 



TABLE OF CONTENTS. 



PAGE. 

Preface - - - - - - vii 

CLASS L 

DISEASES OF THE RESPIRATORY ORGANS. 

CHAPTER L 

DISEASES OF THE UPPER AIR-PASSAGES. 

Article I. — Coryza - - 25 

II. — Pseudo-membranous laryngitis - 31 

III. — Spasmodic laryngitis - - 52 

IV. — Simple laryngitis - . - - - 64 

CHAPTER II. 

DISEASES OF THE LUNGS AND PLEURA, 

Article I. — Pneumonia .... -74 

II.— Bronchitis ---.._ 105 

III.— Pleurisy - - - . . - 119 

IV. — Hooping-cough, ..... 135 

CLASS II. 

DISEASES OF THE DIGESTIVE ORGANS. 

CHAPTER I. 

DISEASES OF THE MOUTH. 

General remarks - - - - - - - 152 

Article I.— Simple or erythematous stomatitis . - 152 

2 



XIV CONTENTS. 

Article II. — Aphthae - „ „ . . .154 

III — Ulcerative or ulcero-membranovxs stomatitis - 158 

IV. — Gangrene of the mouth - . . - 163 

V. — Thrush - . . „ . . J77 

CHAPTER II. 

DISEASES OF THE THROAT. 

Article I — Simple or erythematous pharyngitis - „ - 197 

II. — Pseudo-membranous pharyngitis - 204 

CHAPTER III. 

DISEASES OF THE STOMACH AND INTESTINES'. 



General remarks 



215 



SECTION I. 

FUNCTIONAL DISEASES OF THE STOMACH AND INTESTINES. 

Article I. — Indigestion ---__„ 218 

II. — Simple diarrhoea - 232 

SECTION II. 

DISEASES OF THE STOMACH AND INTESTINES ATTENDED WITH APPRECIABLE 
ANATOMICAL LESIONS. 

Article I. — Gastritis --.„„_ 244 

II. — Entero-colitis » 254 

III. — Cholera infantum - 288 

IV. — Dysentery - ... . . - 318 



GLASS III. 

DISEASES OF THE NERVOUS SYSTEM. 
General remarks .-.«,., 390 



COKTEK T S. XV 



CHAPTER I. 



kSES OF THE NERVOUS SYSTEM ATTENDED WITH APPRECIABLE ANATOMICAL 
ALTERATIONS. 

Article I. — Tubercular meningitis - 324 

II. — Simple meningitis, - 352 

III. — Acute hydrocephalus - 363 

IV. — Cerebral congestion - - - - 368 

V. — Cerebral hemorrhage ----- 373 

CHAPTER II. 

NEUROSES, OR DISEASES OF THE NERVOUS SYSTEM UNATTENDED WITH APPRECIABLE 
ANATOMICAL ALTERATIONS. 

Article I. — General convulsions or eclampsia, - - 386 

II. — Laryngismus stridulus - 407 

III. — Contraction with rigidity ... - 428 

IV.— Chorea - - - - - - 433 



CLASS IV. 

ERUPTIVE FEVERS. 

Article I. — Scarlet fever or scarlatina - - - - 445 

II. — Measles, rubeola or morbilli - 492 

III. — Variola or small-pox - 519 

IV. — Revaccination - 539 

CLASS V. 

WORMS IN THE ALIMENTARY CANAL. 

General remarks ...... 543 

Article I. — Ascaris lumbricoides - - - - . 548 

II. — Ascaris vermicularis ... - 564 



26 CORYZA. 

measles, scarlet fever, or pertussis. It sometimes exists, however, 
as an idiopathic affection, but is never dangerous unless it occur 
in new-born infants, and assume the purulent or pseudo-membra- 
nous character. It is so mild indeed, that it need not occupy our 
time, and is commonly spoken of as cold in the head, or snuffles. 
The other variety of the disease will constitute the subject of the 
present article, and is that called by Underwood, coryza maligna 
or morbid snuffles. 

Purulent and pseudo-membranous coryza rarely occur as idio- 
pathic affections, but are almost invariably connected with an- 
gina or other diseases. I met with one case, however, of the 
purulent form unaccompanied by angina or other disease, in 1841, 
in a child seven weeks old. The case proved fatal. I saw ano- 
ther fatal case of the same form, connected with simple angina, in 
1846, in a child five weeks old. Besides these two cases, I have 
met with four others of the pseudo- membranous variety, accompa- 
nied by simple angina, in children between two and six years of 
age, all of which terminated favourably. The two varieties of the 
disease occur, however, as already stated, much the most fre- 
quently as secondary affections in the course of other diseases, par- 
ticularly measles, scarlet fever, pseudo-membranous angina, &c. 
I shall not attempt in the present article to treat particularly of the 
cases which accompany the eruptive fevers. 

Causes. — The causes of the disease in the two infants observed 
by myself were unknown. In one the nurse remarked a slight 
discharge of blood from the nose soon after birth, and the coryza 
dated from that time. The other, a feeble child, was attacked 
when two weeks old without any appreciable cause. The re- 
maining four cases occurred in 1845 and 1846, during an ex- 
tensive prevalence in this city of severe scarlet fever, measles, 
and pseudo-membranous angina and laryngitis, which makes it 
probable that they depended upon the epidemic constitution of the 
atmosphere. The cases of Rilliet and Barthez coincided gene- 
rally with primary or secondary purulent or pseudo-membranous 
angina. From the account given by Underwood of coryza 
maligna, there can be little doubt that it was epidemic when 
observed by himself and Dcnman. The latter author states that 
in connexion with the coryza there was general fullness of the 



ANATOMICAL LESIONS SYMPTOMS. 27 

throat and neck externally ; that the tonsils were tumefied, and of 
a dark red colour, with ash-coloured specks, and in some cases, 
extensive ulcerations ; and that some of the children swallowed 
with difficulty ; all of which symptoms clearly point to severe con- 
comitant angina. 

Anatomical lesions. — The Schneiderian mucous membrane is 
found reddened uniformly, or in points, rough, thickened, and 
sometimes softened. When pseudo-membrane is present, it exists 
either in fragments, or lines the whole extent of the nasal pas- 
sages, and is mixed with mucous or muco-purulent fluid, in greater 
or less quantity. 

Symptoms. — Coryza begins with sneezing and stoppage of 
the nostrils, soon after which the discharge, which is the patho- 
gnomonic symptom of the disease, makes its appearance. This 
consists of serous or mucous fluid in greater or less abundance, 
and usually of a yellowish colour, which, at first thin and without 
odour, becomes in slight cases, thicker and often purulent, with a 
peculiar, unpleasant, but not fetid odour. In severe cases, on the 
contrary, and especially when the pseudo-membranous exudation 
is present, the discharge is thin, and often contains small granular 
particles, which seem to be the detritus of the false membrane, 
while at other times it is ichorous or even bloody. When false 
membrane is present, it can often be seen upon examination of the 
nostrils in a strong light, to cover the mucous membrane in the 
form of thin adherent layers of a yellowish-white colour. The 
alee nasi, and sometimes the whole extremity of the nose, are red 
and swelled, and the skin, which is tense and shining, presents 
an erysipelatous appearance. The upper lip is generally reddened, 
irritated, swelled, and sometimes excoriated, by the nasal secre- 
tions. 

The respiration is generally difficult, nasal, and snoring. When 
the nasal passages are nearly or quite filled with the secretions, the 
child being no longer able to breathe through them as in health, 
is compelled to keep the mouth open. This is exceedingly 
inconvenient to children of all ages, as it causes great dryness 
and stiffness of the mouth, tongue, and throat, and in very young 
in (ants, who instinctively respire almost exclusively through the 
nostrils, is attended with such violent efforts, as to be a chief 



28 CORYZA. 

or perhaps sole cause of the fatal termination of some cases. 
In one instance that I saw, the child was seized with attacks 
of suffocative breathing, which threatened fatal asphyxia, when- 
ever the passages became much impeded. Under these circum- 
stances the cleansing of the passages with a brush would afford 
complete relief, and, for a time, the little thing would appear to be 
quite well. Finally, however, death occurred in one of the at- 
tacks of dyspnoea, from sudden serous effusion into the lungs. 
The difficulty of respiration is greater, as I have stated, in propor- 
tion as the child is younger, and depends on the physiological fact, 
that at a very early age, respiration is performed almost solely 
through the nostrils, the child seeming incapable of keeping the 
mouth open, in order to compensate for their closure. I have 
never observed cough except in cases accompanied by angina. 
Epistaxis occurred in two cases of the pseudo-membranous form, 
in children between three and five years of age. The bleeding 
recurred on several occasions, but ceased so soon as the coryza 
was cured. Infants refuse the breast when the passages are much 
clogged, or suckle with great difficulty and at long intervals. 

The character of the general symptoms depends much more upon 
the accompanying disease, in older children, than on the coryza 
itself, and it is unnecessary therefore to dwell upon them. In the 
two infants observed by myself, the principal symptoms were, in 
the case unaccompanied by angina, restlessness, weakness, ema- 
ciation, dry, harsh and wrinkled skin, and violent attacks of 
dyspnoea ; and in the other case, in which angina was present, 
there were added to these, fever and somnolence. Berton gives 
the duration of the disease as from eight to fifteen da}^s, according 
to its intensity. Rilliet and Barthez state that they saw a child 
two years old die in three days, and another of three years in the 
same time ; but as one of these cases was complicated with an- 
gina and croup, and the other with pseudo-membranous angina, 
it is clear that the rapid death depended rather upon the accom- 
panying disease, than the coryza itself. The duration, as ob- 
served by myself, in the two cases occurring in infants, was 
between two and three weeks, in its severe form, in the one unat- 
tended by other disease, and six days in the one accompanied by 
angina. In the other four cases, which occurred in older children, 



PROGNOSIS TREATMENT. 29 

the duration of the attack depended on the form and degree of the 
attendant angina. In one case it became chronic, and was accom- 
panied by ulceration of the nasal passages. 

The prognosis must depend on the age of the child, and the 
nature of the attack. In young infants, simple idiopathic coryza 
is never, perhaps, dangerous ; while the idiopathic purulent or 
pseudo-membranous forms are extremely so. The only two cases 
of the latter kind that I have seen were fatal. The four cases in 
older children recovered without any difficulty. When it occurs 
in connexion with pseudo-membranous angina, or in the course of 
scarlet fever, the prognosis will of course depend on that of those 
diseases. 

Treatment. — Simple coryza requires no treatment in children 
over two years of age, except attention to hygienic conditions. I 
believe that young children may often be preserved from attacks 
of spasmodic laryngitis and of bronchitis, by calling the attention 
' of the mother to the strong tendency which exists during infancy 
and childhood to extension of disease, and advising, in cases of 
coryza, that the child should be secluded in the house, or else very 
warmly clothed, if sent out. 

In infants, even simple coryza gives trouble, by causing ob- 
structed respiration, and consequent restlessness. For these symp- 
toms I have found nothing so useful as passing a small camel's- 
hair pencil loaded with sweet oil, some distance up each nostril, 
and directing the outside of the nose, the openings of the nostrils, 
and the upper lip, to be freely anointed with cold cream, simple 
cerate, or any soft and adhesive ointment. 

In infants labouring under purulent or pseudo-membranous 
coryza, the indications for the treatment are to remove the secre- 
tions as they collect, and to subdue the inflammation of the mucous 
membrane which produces them. The first indication may be 
fulfilled by means of a brush made of long camel's hair, by throw- 
ing water from a small syringe into the nasal passages, or when 
the discharges are thin and fluid, by blowing strongly into the 
nostrils, whilst the tongue is depressed by a finger introduced into 
the mouth, so as to allow the secretions to pass out of the posterior 
nares into the fauces. 

3* 



30 COHYZA. 

The second indication is to be fulfilled chiefly by the application 
of solutions of alum, nitrate of silver, sulphate of zinc or copper, 
and by insufflations of different substances in powder. The best 
application is probably the solution of nitrate of silver, which may 
be made of the strength of five or ten grains to the ounce, or 
stronger, to be made use of several times a day, with a brush. 
I have also employed injections consisting of solutions of alum, of 
from three to six grains to the ounce. It is recommended by 
Rilliet and Barthez to make insufflations of powdered gum and 
alum, or of gum and calomel in equal parts, several times a day. 
There is, however, it seems to me, an objection to this method 
of treatment, especially in infants, which is that the powders 
would necessarily tend to increase the obstruction to breathing 
through the nose, already existing. It has been proposed also to 
apply a few leeches to the mastoid process, or over the frontal 
sinuses. This might be done in hearty children. 

In the form of the disease accompanied with angina, an essen- 
tial part of the treatment must be that of the throat-affection. This 
will be considered in another place. 

Case. — The subject of this case, a male, was born after an 
easy, natural labour, and appeared strong and well, with the ex- 
ception of a little discharge of blood from the nose soon after birth 
and slight coryza, the latter of which continued until the child was 
five weeks old, when it became aggravated, and my father was re- 
quested to visit the infant. I saw it at the same time. It was 
small and puny; the skin was harsh, dry, and wrinkled, so that the 
child looked like a little old woman. It was very weak, and had 
constant secretions from the nostrils of thick, dark-coloured pus. 
When the discharge collected in sufficient quantity to obstruct the 
passages, the respiration became exceedingly difficult, as the little 
thing seemed incapable of breathing through the mouth, and at such 
moments it seemed as though the child must die of asphyxia. If 
the nostrils were cleared by any means, by syringing, by the use 
of a brush, or by blowing into them in the manner already de- 
scribed, the respiration would become easy and natural, until the 
discharge collected again, when the same scene recurred. During 
the paroxysms arising from the closure of the nasal passages, the 



PSEUDO-MEMBRANOUS LARYNGITIS. 31 

child was entirely unable to take the breast, but after being relieved, 
had no difficulty whatever ; the mouth was either kept shut, or if 
open, the tongue was observed to be pressed spasmodically against 
the roof of the mouth, so that it was impossible for more than 
a very small amount of air to pass through it ; the respira- 
tion was laboured, and accompanied by a loud snoring or nasal 
sound. There was no other marked symptom, except a nearly 
constant flatulent distension of the epigastric region. On the day 
before death, the infant seemed better, appeared to have gained 
flesh, and looked more intelligent, so that the mother was greatly 
encouraged ; but the next day it was seized during one of the 
paroxysms of suffocation, which did not seem to be worse 
than many preceding ones, with copious discharges of bloody 
and frothy serum from the mouth and nose, and died in about 
three quarters of an hour. 

At the post-mortem examination we were not allowed to exa- 
mine the nasal passages or throat. The stomach and bowels 
were healthy, but much distended with gas. The peritoneum 
was healthy, but contained a considerable amount of clear yellow- 
ish serum. There was serous effusion in both pleural cavities, 
but no traces of inflammation. The lungs were healthy, with the 
exception of some ecchymosed points, and general infiltration with 
sanguineous frothy serum. The trachea and bronchia were natural. 
The heart was larger than usual, but healthy in other respects. 



ARTICLE II. 

PSEUDO-MEMBRANOUS LARYNGITIS. 

I shall describe three forms of laryngitis, — the pseudo. mem- 
branous, spasmodic, and simple or erythematous. 

It seems evident from the recent works on diseases of children, 
that there are two distinct disorders, which have until within a 
few years, and which are even now by many in this country, con- 
founded together under the appellation of croup. In fact it is the 



32 PSEUDO-MEMBRANOUS LARYNGITIS. 

custom in many parts of the United States, to apply the term 
croup to all the affections of the larynx characterized by dyspnoea, 
hoarse spasmodic cough, and croupy respiration ; whereas there 
are four different maladies which present in a greater or less 
degree the symptoms just mentioned. These are : pseudo-mem- 
branous laryngitis, or true croup ; spasmodic laryngitis, or false 
croup ; simple laryngitis ; and laryngismus stridulus, or spasm of 
the glottis. 

Underwood describes pseudo-membranous and spasmodic laryn- 
gitis as a single disease, under the title of suffocalio stridula; 
Dewees under that of cynanche trachealis, or croup; and Eberle 
of cynanche trachealis, tracheitis, or croup. Underwood evidently 
describes laryngismus stridulus in his chapter on inward fits ; 
Dewees has nothing in regard to it ; while in Eberle's work it is 
easily recognised under the title of carpo-pedal spasms. 

Definition; synonymes ; frequency. — Pseudo-membranous la- 
ryngitis is an acute inflammation of the mucous membrane of the' 
larynx, attended with exudation of false membrane. 

It is the croup of the French writers, and is called in this coun- 
try slow, creeping, true, membranous, or inflammatory croup. 
The term given above seems most suitable, as expressive of the 
real nature and seat of the disease, and I shall therefore make use 
of it in contradistinction to that of spasmodic laryngitis or spas- 
modic or false croup, which is a much more common and less 
dangerous form of disease. 

The frequency of the disease is very considerable. During the 
ten years preceding 1845, there occurred in this city, according to 
Dr. Condie (Dis. of Child., Note, p. 88), 3977 deaths under fifteen 
years of age, from bronchitis, croup, pneumonia, hooping-cough, 
and other diseases of the respiratory organs. Of this number, 1 149 
were from croup alone; and as spasmodic croup is seldom a fatal 
disease, it is reasonable to conclude that much the larger number of 
these deaths were from the disease under consideration. It is rare, 
however, it seems to me, in comparison with spasmodic laryngitis, 
or as it is called here, croup. During the last five years, I have seen 
twelve cases of primary pseudo-membranous laryngitis, and in the 
same period, thirty-one of primary spasmodic laryngitis, of which 



CAUSES. S3 

I have kept a record, and a considerable number of additional 
cases of which I have no written account. 

Predisposing causes. — Age. — The disease is most frequent be- 
tween the ages of two and seven years. Of the twelve cases that 
I have seen, ten occurred between two and seven years of age, 
and the other two at eighteen months and eleven years, respec- 
tively. As to sex, it is said to be more frequent in boys than girls. 
A feeble, delicate constitution is thought by some to be a power- 
ful predisposing cause, though this is contrary to the experience 
of Rilliet and Barthez. 

Of the twelve cases referred to all but two occurred in healthy, 
vigorous children, and these two were neither very weak nor very 
sickly, but presented a rather more delicate appearance than usual. 
Season appears to exert some influence as a cause, since the disease 
is apt to be most prevalent in spring and autumn. It is either 
sporadic or epidemic, resembling in this respect pseudo-membra- 
nous angina. When epidemic it is very generally connected with 
angina, while the sporadic cases frequently begin in the larynx, 
and often run their course without implicating the pharynx. Du- 
ring the latter part of the year 1844, the whole of 1845, and a 
part of 1S46, the disease prevailed extensively in this city, and 
was in many cases accompanied by the pharyngeal affection. 
During those years, and particularly in 1845, measles and scarla- 
tina also prevailed to a great extent, especially the former. 

Is the disease contagious ? In the article on pseudo-membranous 
angina, it will be stated that some of the most distinguished autho- 
rities unhesitatingly pronounce that disease contagious. In regard 
to the one under consideration, more doubt is expressed, and both M. 
Valleix, and Rilliet and Barthez, say that additional facts are neces- 
sary to determine this point. My own experience has never given 
me the least reason to suppose that it is propagated in this man- 
ner, as I have not known it extend from one child to others in the 
same family. 

The exciting causes are but little understood. The only ones 
which seem to have been ascertained with any certainty, are the 
application of irritating agents to the laryngeal mucous membrane, 
and exposure to cold ; and even these are questioned by the most 



34 PSEUDO-MEMBRANOUS LARYNGITIS. 

accurate observers. In none of the cases that I have seen, could 
the exciting cause be even suspected. 

Anatomical lesions. — The false membrane may cover the whole 
of the mucous membrane of the larynx, and extend into the pha- 
rynx, trachea, and even bronchia, or it may be confined to the 
larynx, forming a complete lining to the cavity of that organ, or 
consisting merely of patches of various sizes, with intervals of mu- 
cous membrane between, destitute of exudation. It would seem 
that the membrane is confined to the larynx and trachea in about 
two-thirds of the cases, while in the other third it implicates the 
bronchia. The proportion of cases in which the pharynx is at- 
tacked is uncertain. According to M. Valleix, M. Hache found 
false membrane on the tonsils in only half of the cases. 

The false membrane is generally of a yellowish-white colour, 
and from a fifth of a line to a line in thickness. Its consistence 
is generally considerable, and it is usually somewhat elastic. The 
free surface is usually covered with puriform mucus, while the 
inner surface is adherent with various degrees of force to the 
mucous membrane beneath. It consists, according to Hasse, 
mainly of fibrine blended with mucus in various proportions. 
(Patholog. Anat., Syden. Soc. Edition, p. 278.) 

The mucous membrane presents various shades of redness, or 
is violet-coloured, or even blackish. In other cases it retains its 
normal characters, a circumstance which has given rise to the 
opinion entertained by some persons, that the disease is not in- 
flammatory, though it is altogether probable that this condition is 
consecutive to the formation of the exudation. The membrane 
is sometimes brittle, friable, and thickened, and in rare instances 
softened. 

Bronchitis and lobular pneumonia are frequent complications of 
the disease ; the other organs are healthy in the great majority of 
cases, with the exception of venous congestion. 

In the secondary croup of measles the appearances are very 
similar to those observed in primary cases, while in that of scarlet 
fever the exudation differs in being less consistent and less uni- 
formly spread over the diseased part. In the last-named malady 



SYMPTOMS. 35 

the membrane is thinner, less adherent, and softer, and in some 
cases puriform, soft, and of a grayish colour. It is usually poor 
in fibrine, and prone to decomposition. The mucous membrane 
is generally discoloured and softened. 

Symptoms. — It is highly important to ascertain the proportion 
of cases in which the disease commences in the larynx,, and those 
in which it begins in the pharynx. It is difficult, however, to 
determine this question in the present state of knowledge upon 
the subject, as it has not been carefully examined by a sufficient 
number of observers. Rilliet and Barthez state that a majority 
of the cases observed by themselves, and also of those of M. 
Hache, commenced in the larynx. M. Guersent, on the contrary, 
[Diet, de Med., t. ix. p. 339) asserts that in nineteen-twentieths oi 
the cases, it begins in the pharynx, and I have heard some physi- 
cians in this city assert that the diagnosis between the disease and 
common or spasmodic croup, cannot be considered as positive 
during life, unless the pharynx contains an appreciable amount 
of pseudo-membranous exudation. From this I entirely diner. 
and believe, on the contrary, that the disease may exist in the 
larynx without at all implicating the pharynx in some cases, while 
in a considerable number the pharyngeal complication is exceed- 
ingly slight. Of the 12 cases that I have seen, the attack com- 
menced with angina only in 3 ; in 2 of the remaining 9 there was 
no angina ; in 3 there were no pharyngeal symptoms, so that the 
state of the throat was not examined ; whilst in the remaining 4, 
all of which began with laryngeal symptoms, there was fibrinous 
exudation in the pharynx, confined however entirely to the tonsils. 
It is probable that the disease is most apt to begin in the pharynx 
in epidemic cases, while in those which are sporadic, it most fre- 
quently begins in the larynx. 

When the disease begins in the pharynx the early symptoms 
are the same as those of pseudo-membranous angina. After a 
longer or shorter period, from one to seven days usually, accord- 
ing to the nature of the epidemic, the malady extends into the 
larynx, causing cough and hoarseness, and then follows the same 
course as when it commences in that organ. When, on the con- 
trary, it begins in the larynx, the invasion is marked by hoarse- 



36 PSEUDO-MEMBRANOUS PHARYNGITIS. 

ness of the voice, and hoarse, croupal cough, which often continue 
for one, two, or three days, until the disease has made considerable 
progress, before the parents deem it necessary to send for a physi- 
cian. In one case that came under my observation, the child was 
playing about the room at a time when he had hoarse, whispering 
voice and cough, and stridulous respiration. In another I was 
not called until the evening of the third day, though the child had 
had stridulous cough and respiration for two nights, but, as he 
always seemed better in the morning, it was not thought necessary 
to send for me until after he had become violently ill. In a third 
there was hoarseness of the voice and slight croupal cough during 
the afternoon of one day and the ensuing night, and the next morn- 
ing fully developed croup, with fibrinous patches on each tonsil. 

These symptoms are not generally accompanied by fever at 
first. The appetite is usually unimpaired, the thirst scarcely 
augmented, and the child, though somewhat dull and languid, 
is disposed to be amused at times. In other and severer cases, 
on the contrary, the disease becomes aggravated much more 
rapidly, and may soon lead to a fatal termination. 

The change of the voice is the first symptom observed in the 
cases which begin in the larynx. It was always described to me 
as hoarse, like that which is heard in an ordinary cold. As the dis- 
ease progresses, the voice becomes more and more hoarse and diffi- 
cult, until at length it is reduced to a mere whisper. The degree of 
the hoarseness varies however to a very great degree, the diversities 
depending probably upon the amount of the spasm of the larynx at 
the moment, and upon the state of the exudation. I have several 
times observed it to become much stronger and clearer after the ope- 
ration of an emetic, in consequence no doubt of its relaxing effect 
upon the glottis. The cough is peculiar. At first slightly hoarse, 
it becomes, as the case goes on, very hoarse and hollow, and then 
short and smothered. It is variable in frequency and is apt to 
occur in paroxysms, which are often very troublesome from their 
frequent recurrence. Towards the termination of the disease in 
fatal cases, or whenever the case is very severe, it is altogether 
different from what it was at the beginning, becoming short, in- 
stantaneous, and smothered, so that it might very well be called 



SYMPTOMS. 37 

whispering. As the case advances it is accompanied by stridulous 
respiration, in which a hoarse, rough, hissing, or crowing sound 
is produced by the rush of the air through the constricted larynx. 
This sound is usually heard at first only during forced inspirations, 
and is therefore noticed first during the long inspiration which 
precedes coughing. Next it is heard during the violent respira- 
tory movements which accompany the act of crying ; and as the 
larynx becomes more and more clogged with the exudation, it 
occurs during both inspiration and expiration, in every respiration, 
and is so loud as to be heard over the whole room, or even in 
adjoining rooms. 

The respiration is natural in the early part of the attack, but 
as the voice and cough assume their characteristic features, and 
the stridulous sound is established, it becomes more frequent, rising 
to 28, 32, 40, and 48, in the minute. At first easy and natural, 
it assumes during the height of the symptoms, and especially 
in fatal cases, the most frightful orthopnoea I have seen in any 
disease. Every movement of inspiration requires the whole force 
of the inspiratory muscles to lift the walls of the chest, and enable 
the air to find its way through the narrow and obstructed glottis ; 
each expiration, instead of being short and easy, as in health, and 
in nearly all other diseased conditions, requires a slow and 
laborious contraction of the expiratory muscles to expel from the 
lungs the air which they contain, and which hisses through the 
larynx with a sound nearly as loud as that produced during in- 
spiration. The orthopnoea just described occurs sometimes in 
paroxysms, but at other times is constant. In only one of my 
cases did it assume the form of paroxysms, and in that the patient 
recovered. In the others, both favourable and unfavourable, it 
was constant, or at least the variations were slight, and dependent 
chiefly upon the action of emetics. 

When the orthopnoea occurs in paroxysms, the expression of the 
child is that of the most terrible anxiety, or of the wildest terror. 
In one instance, the face became deeply red, then blue, livid, and 
finally pale and white, and for a moment life seemed extinct. In the 
other cases, in which dyspnoea was constant, the face was of a dusky 

4 



38 PSEUDO-MEMBRANOUS LARYNGITIS. 

red colour, the expression anxious and haggard, and the child either 
laid on its side with the head thrown far backwards in a state of 
somnolence or was constantly changing its position, from restless- 
ness, without noticing anything around it. 

There is no expectoration early in the disease, or it con- 
sists of white or yellowish viscous mucus. At a later period, 
there is often expectoration of false membrane, sometimes in the 
form of a complete tube, or much more frequently, of small irre- 
gular fragments, mixed with mucus, or with the matters ejected by 
vomiting. To detect the membrane, the substances expectorated 
or vomited ought to be placed in water, when it detaches itself 
from the mucus and other matters, and is easily recognised. 
It is not present in all the cases. Thus, of the 12 cases observed 
by myself, it was expelled by vomiting or coughing only in 3 ; in 
6 it was known to be present by the character of the symptoms 
and by its existence in the pharynx ; in 2, there was expectora- 
tion of masses of viscid, yellowish fibrine ; and in the remaining 
cases, there was no positive evidence of its existence. M. Val- 
leix {Guide du Med. Prat., tome i., p. 330) states that of 51 
cases, in which the symptoms were very carefully observed, no 
traces of the exudation could be discovered either in the expec- 
toration or in the matters rejected by vomiting in 26, though their 
existence was proved by post-mortem examination. 

Auscultation. — Barth and Roger ( Trait. Prat, d' 'Auscultation, 
2d ed. p. 255 and 261) describe, as a sign of croup with floating false 
membrane, a kind of vibrating murmur, or tremblotement, as though 
a moveable membranous veil were agitated by the air, which can 
be heard when the stethoscope is applied over the larynx or trachea. 
If this sound is heard only in the larynx, and not in the trachea 
and bronchia, it indicates the plastic exudation to be of small ex- 
tent, and likely to be rejected by expectoration, and the prognosis 
is favourable. In the other case, on the contrary, it shows the 
disease to be of considerable extent, and the prognosis becomes 
much more serious. The vesicular murmur of respiration is 
masked by the laryngeal stridulous sound, when this is present. 
When absent, the respiration is natural, or altered according to 
the state of the lun^. 



SYMPTOMS AND TERMINATION. 39 

There is a slight febrile movement at the onset, or a day or two 
after the appearance of the earliest symptoms. When the disease 
is fully established, the fever becomes violent, and the pulse rises 
to 130, 140, 160, or even higher. It is generally regular and 
strong at first, but as the case progresses, becomes small, feeble, 
and very rapid. In one of the paroxysms that I witnessed, it be- 
came so rapid that it could not be counted, and at last ceased to 
beat at either wrist for a few instants. The heat and dryness of 
the skin are very moderate at first, but increase as the disease 
reaches its maximum, to diminish afterwards gradually, and in 
fatal cases, to be replaced by coldness, with copious clammy per- 
spirations. The strength is not diminished at first, but as the 
disease progresses, is more or less so in proportion to its violence 
and duration. The digestive organs are but little disturbed by the 
influence of the disease, with the exception of diminution or loss of 
appetite, and moderate thirst during its violent period. Sponta- 
neous vomiting cr diarrhosa are rare, though both sometimes occur. 
The tongue is moist, and generally covered with yellowish-white 
fur. Pain in front of the larynx has been noticed by several 
authors. I have never observed it. 

Tumefaction of the sub-maxillary glands, which is a frequent 
symptom of pseudo-membranous angina, ought always to be sought 
for, and if present, lends additional support to the diagnosis. 

In favourable cases the recovery is sometimes very sudden in con- 
sequence of the expectoration of a tubular-shaped membrane. This 
is a very rare event, however, and recovery does not always follow. 
In general the recovery is slow and gradual. After free vomiting, 
after the expectoration of fragments of false membrane mixed with 
mucus, or, as happened to myself in two cases, after the expecto- 
ration of masses of tough, yellowish fibrine, or lastly, after the 
rejection of mucoid and frothy sputa only, the symptoms gradually 
ameliorate ; the stridulous respiration slowly subsides, and at last 
disappears ; the cough, which was short, hoarse, and smothered, 
became louder, stronger, less hoarse, and, what is still more fa- 
vourable, loose; the aphonia moderates, but very slowly; the 
fever disappears ; appetite and gaiety return ; and after a va- 
riable length of time, the child enters into full convalescence. 



40 PSEUDO-MEMBRANOUS LARYNGITIS. 

The hoarseness of the voice very generally continues for several 
days after all the other symptoms have lost their dangerous cha- 
racter, and sometimes lasts for weeks. In one case, the voice was 
still weak and hoarse on the tenth day, and in another during the 
seventh week. (See a paper on croup, by the author. Am. Jour. 
Med. Sci., April, 1847.) 

Duration. — Death has been known to occur on the first, second, 
and third days, but such cases are rare. The duration of the 
disease may be stated at from three to thirteen days, as its most 
common term. The cases seen by myself, lasted from five to 
fourteen days. 

Diagnosis. — The diagnosis of the disease, when it follows pseu- 
do-membranous angina, presents no difficulty whatever. When, 
on the contrary, it commences in the larynx, as we have seen that 
it often does, especially in sporadic cases, it may be confounded 
with stridulous laryngitis or sporadic croup, and with simple laryn- 
gitis. The mode of distinguishing between them will be described 
under the head of the two last-mentioned affections. 

Prognosis. — Pseudo-membranous laryngitis is a very fatal dis- 
ease. Rilliet and Barthez state that its common termination is in 
death. M. Valleix says that " to speak in general terms, it is fatal 
when not treated energetically." Guersent (Loc. cit. p. 365), after 
a careful consideration of the statements of different authors, says : 
" In fact, true croup is one of the most dangerous of all diseases, 
and is generally fatal." He adds that he has seen at least a 
hundred cases of spasmodic croup, without a single death, while 
of ten children attacked with true croup, it is scarcely possible to 
save two. The degree of mortality is very strikingly different in 
different epidemics. Thus of sixty cases observed by M. Ferrand 
in the villages about La Chapelle Veronge, not a single one 
escaped. Other writers speak of having cured three or four in 
forty, and others nearly all. Dr. Bard, of New York, says, that 
of sixteen cases, seven died. Of the 12 cases that I have seen, 
6 died. Of the 12, 3 commenced with violent pseudo-membra- 
nous angina, of which 2 died. The remaining 9 began in the 
larynx, and of these 4 died, and 5 recovered. From personal 
experience I would conclude that the sporadic are less dangerous 



PROGNOSIS TREATMENT. 41 

than epidemic cases, though the mortality is frightful even in 
those. 

The danger is great in proportion as the child is younger and 
more feeble, in proportion to the rapidity of the case, and to the 
degree of the dyspnoea or orthopncea. The most unfavourable 
symptoms are : loud stridulous sound heard both in the inspiration 
and expiration ; laborious and prolonged expiration ; whispering 
voice or complete aphonia ; congestion of the face and neck ; 
somnolence ; weak, rapid, and irregular pulse ; cold extremities ; 
and cold clammy perspirations. The favourable symptoms are : 
expectoration of false membrane ; diminution of the stridulous 
respiration ; the change from whispering to hoarseness or clear- 
ness of the voice ; looseness of the cough ; moderation of the 
fever ; improvement of the temper and moral state ; and ame- 
lioration of the general condition. 

The case should not be abandoned as hopeless until life is ac- 
tually extinct. I myself saw a child recover after momentary 
suspension of animation, -by asphyxia, on two occasions, and 
though these attacks were followed by a dreadful illness of two 
days. (See paper by the author. Loc. cit.) 

Treatment. — I am desirous, at the beginning of my remarks 
upon the treatment of the disease, to express the opinion, that 
none is likely to succeed, unless it be applied early in the case, 
and by this I mean, in the course of the first, or at the latest, 
second day. And not only should it be commenced early, but 
the most powerful remedies ought to be applied at this period, 
in their full force. The very moment there is good reason 
to suppose that a case will prove to be one of this disease, the 
most energetic means ought to be brought to bear upon it, and if 
this be done from the first, or even second day, I cannot but hope 
that a considerably larger proportion of recoveries may take place, 
than has heretofore been thought possible. Of seven cases that 
were treated in the manner I shall recommend, from an early 
period in the attack, five recovered. Of five cases not so treated, 
only one recovered. Of the latter cases, I saw three in consulta- 
tion, late in the attacks, and the other two several years since, 

4* 



42 PSEUDO-MEMBRANOUS LARYNGITIS. 

before I fully understood the importance of early and energetic 
treatment. 

In the study of the treatment, it will be necessary to rely 
chiefly upon the works which have been published since the dis- 
tinction between the two forms of croup has been correctly drawn, 
for it is impossible to place much dependence on the asser- 
tions of previous writers, inasmuch as their opinions as to the 
effects of treatment have been formed from indiscriminate expe- 
rience in two very opposite maladies. It is only necessary to re- 
collect the enormous difference in the mortality of the two affec- 
tions, to be convinced that the success of such or such a plan in 
the one, is no fair argument for its probable success in the other. 
Thus M. Guersent has seen a hundred cases of spasmodic laryn- 
gitis, without a single death ; while he believes that of ten cases 
of pseudo-membranous disease, scarcely two can be saved. I have 
a record of thirty-one cases of spasmodic croup, and have seen a 
considerable number of cases besides, of which I have no notes, 
without a single death ; whilst of twelve cases of true croup that 
I have met with, six proved fatal. The most important objects 
to be held in view in the treatment are, it seems to us : to pre- 
vent, if this be at all possible, the formation of false membrane ; 
after its production, to cause its dissolution, or render it less ad- 
herent ; to provoke its expectoration ; to prevent its reproduction 
after it is once expelled ; to subdue the inflammatory diathesis 
which exists ; and to allay the painful symptoms. 

Bloodletting. — Many authors award to bloodletting the first 
place in importance amongst the remedial means in our posses- 
sion, and it seems to be regarded by many in this country as an 
indispensable agent in the cure. Moreover, there are not a few 
who believe that, when promptly and boldly resorted to, it will 
seldom fail in arresting the disease. Underwood says (BelFs Ed., 
p. 273) : " Bleeding is always necessary, if the physician be 
called at the commencement of the disease, or stridulous noise ; 
and if the patient be visited too late to endure this evacuation, I 
believe no hope can remain of his being benefited without it, unless 
the infant be very young; which, however, in another view, can- 
not but add to the danger." Dewees recommends it very highly 



TREATMENT. 43 

in fully developed cases attended with fever, and advises it to 
be repeated if the symptoms persist. Eberle says (Dis. of 
Child., p. 356) : " Without doubt, however, the remedy upon 
which our principal reliance should be placed, for the removal 
of the tracheal inflammation is bloodletting." Dr. Con die (Dis. 
of Child., 2d edit., p. 305) recommends it as the most effectual 
remedy in arresting the disease, and says that " the practitioner, 
who in violent cases, neglects this important measure, and places 
his hopes on any other remedy, or combination of remedies, will 
have but little reason to flatter himself upon his success in the 
management of the disease." Unfortunately for us, the value of 
the opinions just quoted is very much diminished by the fact that 
the authors who emit them, have not clearly distinguished be- 
tween the two varieties of the disease, so that their experience is 
derived in part at least from the effects of the remedy in spasmo- 
dic croup ; and, as it is now well known that that disease is very 
readily cured in the vast majority of cases, it is easy to under- 
stand the confidence they express in the utility of any means 
which they may have employed. 

But if we examine the works of those who have made the dis- 
tinction between the two diseases, we shall find different opinions 
from the above, expressed, in regard to the efficacy of bloodletting. 

Guersent (Loc. cit., p. 373) asserts that bleeding has not the 
power of arresting the progress of this specific inflammation, — that 
the disease continues with greater or less rapidity under the influ- 
ence of general and local bleedings, and almost always terminates 
fatally, though the detractions of blood may have been pushed to the 
utmost limit. Bretonneau is of opinion that it has no effect in pre- 
venting the formation of the false membrane. Valleix (Loc. cit., 
p. 353) says : " From the examination of a large number of cases, 
I am convinced, with M. Bretonneau, that bleeding, whether gene- 
ral or local, is not a powerful curative means, and that it does not 
obviously arrest the progress of the disease." Rilliet and Barthez 
(T. i., p. 262) are of opinion that bloodletting ought to be resorted 
to only in vigorous children ; in the early part of the attack in 
sporadic cases ; and in those in which the febrile reaction is vio- 
lent, and the suffocative symptoms strongly marked ; while it 



44 PSEUDO-MEMBRANOUS LARYNGITIS. 

ought to be abstained from in epidemic and adynamic cases ; in 
young, pale, and lymphatic children ; when the fever is slight ; 
the dyspnoea moderate ; and lastly, that it ought never to be em- 
ployed in the advanced stage of the disease. Dr. Wood ( Trea- 
tise on the Pract. of Med., vol. i. p. 788), in his remarks on 
the treatment of the disease, says : " Depletion, in this variety of 
croup, is much less efficient than in the catarrhal." He adds that 
the utmost to be expected from it is, that it may moderate the 
severity of the inflammation, and thus probably diminish the 
amount of the effusion. 

I proceed now to state the results of my own experience as to 
its effects. It was employed in two of the three cases which be- 
gan as angina ; in one the child was bled once and leeched once, 
and recovered ; in the other, leeches were used and the case ter- 
minated fatally ; in neither of them could I perceive that the de- 
pletion exerted any positive control over the symptoms of the dis- 
ease. In the third case, no bloodletting was employed, and it 
also proved fatal. Of the nine remaining cases, all of which com- 
menced in the larynx, it was employed in all. Of them, two of the 
subjects were eighteen months old ; two, two years ; four, three 
years ; and one, six. All were bled from the arm, and in two, 
leeches were applied to the neck besides. A single venesection of 
four ounces was employed in seven, while in two, a venesection of 
about the same amount was performed three times in each. Of 
the nine cases five recovered and four died. The two cases bled 
to the largest amount (three times each), recovered. In one of 
these there were small patches of fibrinc on each tonsil, and rejec- 
tion of false membrane by coughing and vomiting. 

The immediate effects of the bleeding in the second series of 
cases were decidedly more beneficial than in those following an- 
gina ; they were diminution of the fever and dyspnoea. In none, 
however, was the relief from bleeding so great as that which fol- 
lowed the free operation of an emetic, and be it remarked, that 
emetics were freely employed in all. 

Emetics. — This class of remedies is recommended by all 
writers, and is generally acknowledged to be one of the most, if 
not the most important, of all the means employed. M. Valleix 



TREATMENT. 45 

(Loc. cit., t. i. p. 358), has demonstrated their importance more 
fully than any other writer. He states that of 53 cases of the 
disease, tartar emetic and ipecacuanha were chiefly relied on in 31, 
of which 15 were cured ; whilst of the 22 others in which they 
were parsimoniously given, not a single one recovered. He states 
other facts in regard to these cases which are highly interesting 
and important. Thus of the 31 cases treated with powerful 
emetics, false membrane was rejected during the efforts of vomiting 
in 26, and of these, 15 or nearly three-fifths recovered. In the 
5 others of the 31, on the contrary, no membrane was expelled, 
and they all terminated fatally. Again, of the 22 cases in which 
emetics formed but a secondary part of the treatment, 2 rejected 
false membrane, and of these one recovered ; while of the 20 others 
in which no false membrane was expelled, not one escaped. 

Of the cases that I have seen, emetics formed a principal part of 
the treatment in one of the three which commenced as angina, 
in one they were used to a slight extent, and in the third not at 
all. The first one recovered, the others died. In none of them 
was there rejection of false membrane. They were used ener- 
getically and frequently repeated, in 8 of the 9 cases commencing 
as laryngitis, 5 of which recovered. The remaining case, in 
which they were used as secondary means, proved fatal. In 3 
of the 8 cases, fragments of false membrane were rejected, and 
in a fourth, a mass of viscid yellowish fibrine. Of the 4, 3 re- 
covered. In none of the remaining 5 was there any expulsion of 
false membrane, and of these, 3 died. 

It seems to me that these facts are sufficient to show that 
emetics exert a most powerful and beneficial influence on the 
disease, and that they ought, therefore, to enter into the treatment 
as principal remedies. 

The emetics generally employed in Europe and this country 
are tartar emetic and ipecacuanha, which are given in the usual 
doses to produce full vomiting. I have been in the habit of em- 
ploying a substance as an emetic, which, so far as I know, was 
first recommended for that purpose by my father. The substance 
to which I refer is the alumen of the pharmacopoeia. In an article 
published by my father in the Med. Examiner, (vol. i. p. 414, 



46 PSEUDO-MEMBRANOUS LARYNGITIS. 

1838), he says he has been "accustomed to make use of an emetic, 
which, so far as I can learn, is very little employed, but which, 
from the certainty and the speediness of its operation, ought to be 
more generally admitted into the list of available medicines for 
this particular case at least. I have been familiar with its effects 
for more than twenty years, and my confidence in them increases 
rather than diminishes by time." He adds, " I think that I have 
never given more than two doses without causing very full vomit- 
ing ; but I have often given large quantities of antimonial wine 
and ipecacuanha, without succeeding in exciting the efforts of the 
stomach." 

The alum is given in powder, in the dose of a teaspoonful, mixed 
in honey or syrup, to be repeated every ten or fifteen minutes until 
it operates. It is very seldom necessary to give a second dose, 
as one operates in the majority of cases very soon after being 
taken. I have known it to fail to produce vomiting only in two 
instances, both of which were fatal cases. In one the disease had 
gone so far before I was called, that no remedy had any effect 
upon the stomach. In the other, it was administered several 
times with full success, but lost its effect at last, as had happened 
also in regard to antimony and ipecacuanha. The reasons for 
which I prefer alum to antimony, or ipecacuanha, are the fol- 
lowing : antimony, when resorted to as frequently in the disease 
as I am of opinion that emetics ought to be, is too violent in its 
action ; it prostrates many children to a dangerous degree, and 
is, I fear, in some cases, itself one cause of death. It acts inju- 
riously upon the gastro-intestinal mucous membrane, when used 
in large quantities, and for any length of time. Again, it is very 
apt to lose its effect, and to fail to produce sickness. Ipecacu- 
anha is a much safer remedy than tartar emetic, but its operation 
is often too mild, and it also ceases to produce any effect after it 
has been used several times. The advantages of the alum are 
that it is certain and rapid in its action, and that it operates with- 
out producing exhaustion or prostration beyond that which always 
follows the mere act of vomiting. It does not tend like antimony, 
and in a less degree ipecacuanha, to produce adynamia of the 
nervous system ; an effect which, in some constitutions or states 



TREATMENT. 47 

of the constitution, or when it has been exhibited frequently, is 
often attended with injurious or even dangerous consequences. I 
have given alum in the dose above mentioned, twice and three 
times a day, for two and three days, without observing any bad 
effects to result from it. The alum was given in ail the cases that 
I have seen, in which emetics were used, and was the only one 
employed when it was found to produce full vomiting, with a single 
exception, — one of the cases accompanied by violent angina, — in 
which ipecacuanha was substituted because of its smaller bulk. 
I have already said that it failed to produce vomiting only in two 
instances. It was the emetic employed in the three cases in which 
fragments of false membrane were rejected, and in that in which 
the yellow viscid fibrine was expelled. Although it did not occa- 
sion the rejection of membrane in the other cases, it operated most 
speedily and efficiently. 

Sulphate of copper has been highly recommended by several 
writers for its emetic operation, and by some German physicians, 
as exerting a specific influence upon the disease, in addition to its 
emetic effect. As an emetic it may be given to a child two or 
three years old, in the dose of from half a grain to a grain every 
fifteen minutes, until it operates. To obtain its specific action it is 
continued afterwards in doses of a quarter of a grain every two 
hours. 

There is another remedy which has been proposed as an emetic 
by Dr. Hubbard, of Hallowell, Maine. This is the turpeth 
mineral, the subsulphate or yellow sulphate of mercury, the 
hydrarg. sulphas, flavus of our Pharmacopoeia. Dr. H. recom- 
mends it on the grounds of promptness and certainty, of never 
producing catharsis, and lastly of not being followed by prostration 
like that occasioned by tartar emetic. The dose is two or three 
grains for a child two years old, to be repeated in ten or fifteen 
minutes, until it operates. He says that if the first dose fails, the 
second usually acts as soon as it reaches the stomach. I 
have made trial of this remedy in two cases. The first was one 
in which alum and tartar emetic had lost their power from fre- 
quent repetitions. The orthopnoea was intense, and as I believed 
that the only chance of escape for the child was the operation of 



48 PSEUDO-MEMBRANOUS LARYNGITIS. 

an emetic, I proposed the subsulphate. The age of the child was 
three years. Three grains diffused in syrup were administered, 
which operated powerfully within a few minutes, and when I saw 
the patient one hour after, the distressing symptoms were con- 
siderably ameliorated. The improvement did not last, however ; 
the child died in a state of exhaustion very soon after. The other 
case was that of a boy nine years of age, in whom the alum had 
operated fully, but as it failed to dislodge the membrane, and 
his situation was desperate if not relieved, I made trial of the 
turpeth mineral. Six grains were given in two doses, at fifteen 
minutes interval, but they produced no effect whatever. The case 
terminated fatally, and the whole larynx and trachea were found 
filled with a thick membrane. 

I conclude these protracted remarks upon emetics with the 
statement, that from what I have read, and from personal ex- 
perience, I am induced to regard this class of remedies as the 
most important that we have to oppose to this fearful malady. 
The emetic, whichever it may be, ought to be given at least once, 
generally twice, and sometimes three times in the twenty-four 
hours ; the period and frequency of their administration to be de- 
termined by the stage and urgency of the symptoms, and the con- 
stitution and present strength of the patient. 

Calomel. — Dr. Samuel Bard states that Dr. Douglas of Boston, 
who published in the year 1736 an account of the angina suffo- 
cativa, was the first to recommend the employment of mercury in 
the disease. Bard says that he was induced to try mercurials 
after reading Dr. Douglas's little essay, and adds, "the more 
freely I have used them, the better effects I have seen from them." 
He gave calomel in the quantity of thirty or forty grains in five 
or six days, to children three or four years old ; " not only with- 
out any ill effects, but to the manifest advantage of my patient ; 
relieving the difficulty of breathing, and promoting the casting off 
the slough beyond any other medicine." He recommends that 
the first one or two doses be combined with an opiate. He con- 
siders mercury as the basis of the cure. 

Since it has been so highly recommended by American practi- 
tioners, mercury has been extensively employed and relied on by 



TREATMENT. 49 

European physicians. Bretonneau gave it in large doses, and 
Rilliet and Barthez recommend it in the same way. Valleix, 
on the contrary, doubts whether there are any cases of true croup 
on record, cured by calomel alone. 

Calomel was freely used in 8 of the 12 cases observed by myself. 
Of the 8 cases, 5 recovered, and 3 died. Of the 4 cases in which 
it was not used, 3 died. The largest quantity exhibited in any 
one case, was between forty and fifty grains ; the smallest, eight. 
It ought to be observed, however, that it was given in very large 
doses in the three fatal cases ; in one between forty and fifty, in 
another forty, and in the third between twenty and thirty grains. 
In the successful cases, the quantities given were forty, twenty- 
two, twenty, sixteen, and eight grains. 

It is proposed by some to give it in very large and frequently 
repeated doses. I would recommend it in most cases in the quan- 
tity of two grains every second hour, to children over two years 
of age. If the symptoms were very violent, and the danger im- 
minent, I would give three or four grains every hour, for three or 
four hours, and then administer an emetic of alum. If the child 
is very restless, and if the calomel purges, it would be proper to 
combine a small quantity of Dover's powders with each dose. 

The administration of calomel in large doses, has not been 
followed by bad consequences in any case in which I have used it. 
Nevertheless, it has been known to produce gangrene of the 
mouth, and necrosis of the maxillary bones, and the practitioner 
cannot be too careful to suspend it as soon as may be consistent 
with safety. I would never administer it in this way without first 
informing the parents of the possible danger to which it exposes 
the child, and asking their consent to its employment. 

In addition to the remedies already mentioned, there are 
some which are supported by high authority at home or abroad. 
Amongst them are the sulphuret of potassium, polygala seneka, 
and different alkaline preparations, especially the carbonate of 
potash. There is much difference of opinion amongst French 
writers as to the merits of the sulphuret of potassium, some prais- 
ing it highly, while others deny it all efficacy. I have never used 
it, and can therefore have no personal opinion in regard to its 

5 



50 PSEUDO-MEMBRANOUS LARYNGITIS. 

utility. As to the carbonate of potash and seneka, they may be 
useful as adjuvants, but I am clearly of opinion that they should 
never take the place of emetics and mercurials ; for, as time, 
above all things, is precious in this disease, I would never use 
feeble remedies, to the exclusion of those which are generally 
acknowledged to be more powerful. 

Revulsives often prove useful in allaying restlessness and mode- 
rating the violence of the suffocative attacks. Sinapisms and mus- 
tard poultices applied upon various parts of the cutaneous surface, 
and mustard pediluvia, are amongst the best. The warm bath is 
often highly beneficial in the same way. Blisters are sometimes 
used, but flying sinapisms are preferable. 

Antispasmodics are recommended, and are doubtless useful in 
some cases. The best in the world is, we think, the operation of 
an emetic ; and after this some preparation of opium. 

Hygienic Treatment. — The child ought to be warmly clothed 
and confined to bed. The diet should consist only of the mildest 
fluids during the violence of the attack. If the patient becomes 
weak and feeble, milk, pure or mixed with water, may be al- 
lowed ; or light broths may be given. Towards the termination of 
favourable cases, the diet must be improved slowly and cautiously. 
If great prostration occurs, the powers of the constitution must be 
supported by stimulants and tonics, as wine whey, milk punch, 
and quinine. 

Summary of the treatment. — My own conclusions in regard to 
the treatment are : that bloodletting is a valuable remedy, when 
resorted to in proper cases, and at the proper moment. In the 
form which begins as angina, and which is generally epidemic, 
it ought to be used with more caution than in that which com- 
mences as laryngitis. In the latter form, which is usually 
sporadic, it ought to be used more freely, especially in vigorous 
and hearty children. In children over two years of age, I would 
take from three to four ounces of blood from the arm, once, twice, 
or three times in two days, according to the strength of the child, 
and the degree and obstinacy of the fever. In both forms of the 
disease, emetics, and I would recommend the alum in preference 
to any other, should be given once at least, very often twice, and 
in violent cases, three times in the twenty-four hours, so as to 






TRACHEOTOMY. 51 

produce vomiting attended with a good deal of effort. At the 
same time, I would give, as a general rule, two grains of calomel 
with a quarter or half a grain of Dover's powder, every two 
hours, taking care not to give a dose for an hour before, nor after 
the time selected for the exhibition of the emetic. In cases 
in which there is loud stridulous respiration, heard both in the 
inspiration and expiration, in which previous treatment has had 
no effect, and in which there is threatening of speedy death, I 
would give four grains of' calomel every hour, until three or four 
doses have been taken, and direct the exhibition of an alum emetic, 
after the last dose. 

Seven of the twelve cases so often referred to were -fairly 
treated by the mixed method just described. One I saw with Dr. 
R utter of this city, two with my father, and four I attended myself. 
Of- the 7, 2 died, and 5 recovered. 

Tracheotomy. — The operation of tracheotomy has been seldom 
resorted to in this country, and is, I believe, held in slight favour 
amongst us. Nevertheless, it is recommended as useful and ex- 
pedient by many of the most accomplished French physicians 
and surgeons, and is frequently resorted to as offering an addi- 
tional chance for life. M. Valleix, (Loc. cit., t. i.,) expresses 
himself strongly in its favour, in very violent cases of the disease. 
He states that the success of the operation has, thus far, been as* 
great as that of any treatment devised. Fie founds this asser- 
tion on the results furnished by 54 cases of unquestionable pseudo- 
membranous croup, great care being taken to select only the cases 
in which the diagnosis was positive. Of the 54 cases, only 17, 
or about a third, recovered, and this he states as precisely the re- 
sult, according to himself and M. Bricheteau, of the operation. 
But, as he remarks, the operation was performed in the great 
majority of the cases under the most unfavourable circumstances, 
and not till after all other treatment had been vainly tried, and the 
severity of the symptoms and commencing asphyxia, announced 
impending death. For these reasons he is of opinion, that a single 
cure under such circumstances, is of more weight than several 
obtained in cases where all the resources of the art has been ap- 
plied from the commencement. 



52 SPASMODIC LARYNGITIS. 

For further information upon this subject, and for the method 
of performing the operation, I would refer the reader to the article 
on tracheotomy by M. Valleix (Guide du Med. Prat. t. i. p. 386); 
to the one by M. Trousseau, in the first volume of the work of 
MM. Rilliet and Barthez ; and to that by the same author in the 
Dictionnaire de Medecine (t. ix. p. 381). 



ARTICLE III. 
SPASMODIC LARYNGITIS. 

Definition; synonymes ; frequency. — Spasmodic laryngitis is 
a superficial inflammation of the mucous membrane of the larynx, 
accompanied by spasmodic contraction of that organ, occasioning 
violent attacks of threatened suffocation. 

It is the disease commonly called in this country croup, or by 
those who make the distinction between it and pseudo-membra- 
nous laryngitis or true croup, spasmodic croup. I prefer the 
term spasmodic laryngitis, used by Rilliet and Barthez, because it 
is expressive of the essential characters of the disease. It is the 
stridulous laryngitis of Guersent and Valleix ; the stridulous an- 
"gina of Bretonneau ; the acute asthma of infancy of xMillar ; and 
the spasmodic croup of Wichmann, Michaelis, and Double. It is 
not the laryngismus stridulus described by the English authors, 
Kerr, Ley, and Marsh, which is the same as the thymic, or Kopp's 
asthma of the Germans, and spasm of the glottis of the French. 
It is called by Dr. Wood, in his recent work on practice of medi- 
cine, catarrhal croup. 

Spasmodic laryngitis is one of the most frequent of the diseases 
which occur during childhood in this country. It is so common 
in this city, that almost all mothers who have had any experience 
in sickness, keep some remedy for it in their houses, which they are 
in the habit of resorting to upon their own judgment. I met with 
fifteen cases of the disease during the winter months of 1846-7, 
and in the last three years have seen thirty cases, of which I 



CAUSES ANATOMICAL LESIONS. 53 

have kept a record, besides a considerable number of which I have 
no written account. 

Predisjiosing causes. — Age is a powerful predisposing cause. 
It is said to be most frequent between three and eight years of age. 
From personal observation I should suppose it to be most common 
between one and four years of age. Of the 30 cases referred to, 
3 occurred within the year, 11 between 1 and 2 years, 7 between 
2 and 3, 6 between 3 and 4, and 3 between 4 and 5 years of age. 
It is also said to be more frequent in boys than girls. Of the 30 
cases that I have seen 18 occurred in girls, and 12 in boys. 

The disease is undoubtedly a sporadic one, and is asserted by 
some authors to occur also in the epidemic form. It is generally be- 
lieved to be hereditary _in certain families, and of this I myself have 
no doubt. I am acquainted with one family in this city, in which 
the children for three generations were extremely liable to it; 
with another in which the grandmother and grandchildren were 
frequently attacked ; and with a third, in which the father and 
children showed the same predisposition in the most marked man- 
ner. The idea is, moreover, entertained by many people in this 
community. 

The state of health of the child does not seem to have much in- 
fluence in the production of the disease ; I have seen it occur in- 
differently in the weak and strong. It is most common during 
cold weather. 

Exciting causes. — By far the most frequent exciting cause is 
the action of cold ; either the passage from a warm into a cold 
atmosphere, or prolonged exposure to cold. I was assured on one 
occasion, by a very intelligent lady, that her little daughter had, 
at the age of two years, a well-marked attack of croup, after a 
severe and long-continued fit of crying from some contrariety. 

Anatomical lesions. — M. Vallcix [Guide du Med. Prat. t. i. 
p. 290) says that the accounts of the anatomical lesions are very 
vague, and that these are generally stated to be very slight. A 
little mucus, and slight redness have been observed in some cases, 
but authors have usually been satisfied with stating the larynx to 
be free from any alteration. Dr. Wood ( Treat, on the Practice of 
Medicine, vol. i. p. 779) says : " In some rare instances, no signs 

5* 



54 SPASMODIC LARYNGITIS. 

of disease are discovered in the mucous membrane, and the patient 
has probably died of spasm, consequent upon high vascular irrita- 
tion or congestion, the marks of which disappear with life." I am 
unable to describe the lesions found after death from personal 
knowledge. It appears to me, however, from the study of the dis- 
ease, that it must depend on slight inflammation of the laryngeal 
mucous membrane, for how else can we account for the fever 
which so often accompanies it, the hoarseness of the voice and cry, 
which often remains for some time after the total disappearance of 
the paroxysm, and the loose catarrhal cough which very generally 
follows the attack? 

Symptoms; dilation. — The invasion of spasmodic croup is 
generally very sudden, for though it is often, perhaps in the majo- 
rity of cases, preceded for a few hours or a day or two by slight 
coryza, hoarseness and congh, these symptoms are seldom no- 
ticed at the time, and the child is not supposed to be sick until 
it is seized with the attack of suffocation, which is pathognomonic 
of the disease. This attack occurs in much the larger number 
of cases during the night, and very generally wakes the child 
from sleep. Of the 30 cases observed by myself, it occurred in 
the night in all. The period of the night at which it takes 
place is very irregular ; of 19 cases in which the time was 
noted, it was before midnight in 11, and after midnight in 8; 
which agrees very closely with the statement of Rilliet and Bar- 
thez, that it has been observed most frequently at 11 in the 
evening. The duration of the attacks varies considerably, and 
depends a good deal upon the treatment employed. They may 
last from a few minutes to several hours ; but seldom less than 
half an hour or an hour. The number of the attacks also varies. 
In some cases there is but one, though very generally there are 
several. When the attack occurs early in the night, it is very 
apt to recur again towards morning, and, unless means of preven- 
tion are used, on the following night also, and even, though this 
happens much more rarely, on the third night. As a general 
rule, the first attack is the most severe. 

When the paroxysm comes on, the child is wakened from 
sleep by the sudden occurrence of symptoms apparently of the 



SYMPTOMS DURATION. 55 

most alarming and dangerous character. These consist of loud, 
sonorous, and barking cough ; of prolonged and laboured inspi- 
rations, accompanied by a shrill and piercing sound, to which the 
term stridulous is applied ; of rapid and irregular respiration, 
amounting often to violent dyspnoea, or seemingly impending 
suffocation : the child, alarmed and terrified at its condition, 
and at the fright of those around, its countenance expressive of 
the utmost anxiety, cries violently between the attacks of cough- 
ing, and begs to be taken on the lap, or sits up or tosses itself upon 
the bed, struggling apparently with the disease, which seems for 
the moment to threaten its very existence. The voice and cry 
are hoarse, and sometimes almost extinguished during the height 
of the paroxysms, but become distinctly audible, and often nearly 
natural, in the intervals between them ; differing in this respect 
from pseudo-membranous croup, in which they remain perma- 
nently hoarse or whispering. I have never heard, in this disease, 
the whispering voice and the short smothered cough of true 
croup. The face, head, and neck, are at first deeply flushed, and 
as the paroxysm becomes more violent, assume a dark livid tint, 
which afterwards passes into a deadly paleness, if the attack be 
long continued. These changes in the coloration depend upon the 
arrest of the respiratory function and consequent partial asphyxia. 
The pulse is frequent during the paroxysm, and the skin heated. 
After a longer or shorter period, generally from half an hour to 
an hour, the respiration becomes more tranquil ; the stridulous 
sound disappears entirely, unless the child be disturbed and made 
to cry, when it again becomes distinct ; the cough is less frequent 
and less boisterous, and the child generally falls asleep. The 
attack is very apt to recur towards morning, as has been stated, 
and if not then, the following night. The patient often seems 
perfectly well the day after the first paroxysm, with the exception, 
perhaps, of slight cough. This is no reason, however, for sup- 
posing that the disease will not return in the course of the second 
night, which is almost sure to happen, unless measures be taken 
to prevent it. The cough generally continues for a day or two, but 
soon loses the peculiar character expressed by the term croupal ; 
it becomes less frequent and more loose, and the child is com- 



56 SPASMODIC LARYNGITIS. 

monly well again in two or three days. Sometimes, however, 
the cough lasts for several days, becoming gradually less fre- 
quent, until at last it ceases entirely. 

There is very little fever in moderate cases, for though the 
pulse is accelerated, and the skin warm during the paroxysm, 
these symptoms disappear very soon after that is over. In severe 
cases, on the contrary, there is usually considerable fever, the pulse 
being frequent and full, and the skin hot. The febrile movement 
is most apt to occur after the first paroxysm, as a consequence, 
apparently, of the slight catarrh which remains after the attack. 

In the few fatal cases on record, the paroxysms have generally 
become more frequent and more violent by degrees, and death has 
occurred from suffocation. In other instances, death has been the 
result of prostration, which has probably depended on imperfect 
heematosis. 

Recurrences of the disease are very common, children some- 
times having several attacks in a single winter. This is not the 
case in true croup. I have never known a child to have a second 
attack of that disease. 

The duration is exceedingly variable. Sometimes there is a 
single attack during the night, and the child seems well after- 
wards, with the exception of slight cough, lasting two or three 
days. More generally, there is a return in the course of the 
second night, or, much less frequently, the third, after which the 
proper croupal symptoms disappear entirely, though the child may 
continue to cough for several days longer. The cough usually be- 
comes loose and catarrhal after the last paroxysm, though in some 
few instances, I have known it to retain its hard, barking sound, 
and to be accompanied by slight hoarseness for eight or ten days. 
The average duration may be stated at from one to three days. 

Nature of the disease. — Authors hold very different opinions as 
to the nature of spasmodic laryngitis. We have already seen that it 
is confounded by Underwood, Dewees, and Eberle with the pseudo- 
membranous form of laryngitis. Dr. Che)me {Cyclop. Prat. Med. 
Art. Croup), treats of the two affections as one and the same dis- 
ease, differing only in their degree of violence. Dr. Copland (Did. 
of Prac. Med. Art. Croup), describes spasmodic croup as a variety 



NATURE. 57 

or modification of true or membranous croup. He supposes that 
the modifications of true croup are attributable to " the particular 
part of the air-passages chiefly affected, to the temperament and 
habit of body of the patient, and the intensity of the causes." 
It seems to me, however, that these views as to the nature of 
the two diseases can scarcely be correct, and I am induced 
by personal observation to regard them as distinct affections, 
which may, in the great majority of cases, be distinguished from 
each other at a very early stage, by a careful observer. The 
comparative fatality of the two diseases alone is sufficient to esta- 
blish a wide difference between them. Thus, of twelve cases of 
the pseudo-membranous form that I have seen, six died ; while of 
thirty cases of the spasmodic form of which I have kept a record, 
and a considerable number of which I have no notes, not one was 
fatal. M. Guersent states that of ten cases of the former disease, 
scarcely two escape ; while of upwards of a hundred of the latter 
that he has seen, not a single one was fatal. (Diet, de Med. t. 
ix. p. 365.) The different effects of treatment in the two affec- 
tions again, points out a wide difference in nature. While true 
croup is almost inevitably fatal, unless it is attacked at a very 
early period by the most energetic remedies, by bloodletting, calo- 
mel, and emetics, the spasmodic form seldom resists the exhibi- 
tion of an emetic, a warm bath, nauseating doses of ipecacuanha 
or antimony, or, in the severest cases, a small detraction of blood 
by leeches. When we add to these circumstances, the differences in 
the mode of invasion ; in the cough, voice, and cry ; the fever ; the 
duration ; the state of the constitution ; all of which will be care- 
fully described in the article on diagnosis : it seems to me very 
difficult to resist the conclusion that they are two distinct disorders, 
and not, as has been generally supposed by English writers, de- 
grees or modifications of the same. 

As to the precise nature of spasmodic laryngitis, I have been 
led to adopt the opinion that it depends on slight inflammation 
of the mucous membrane of the larynx, attended with violent 
spasmodic action of that organ. The spasm of the larynx appears 
to be the result of disordered action of the excito-motory inner- 
vation of the part, the irritant which is productive of the morbid 






58 SPASMODIC LARYNGITIS. 

innervation being, in all probability, the slight inflammation of the 
laryngeal mucous membrane, which has been already stated to 
constitute one element of the malady. The nervous element pre- 
dominates in the early part of the attack, but towards the conclu- 
sion, the spasmodic symptoms disappear entirely, and we have left 
only those which depend on the laryngeal inflammation. 

Diagnosis. — Unquestionably the disease with which spasmodic 
laryngitis is most likely to be confounded is pseudo-membranous 
laryngitis, true, or inflammatory croup. The only certain means 
of distinguishing them are the presence of pseudo-membranous ex- 
udation in the fauces, or the rejection of false membrane from the 
larynx in the latter affection. But, though these are the only posi- 
tive single signs, the two diseases may be distinguished with very 
great certainty by a comparison of the different symptoms as 
they arise. The most important are : the invasion, in one sudden 
and almost invariably in the evening or night, in the other, slow 
and creeping, the paroxysm occurring indifferently day or night ; 
the cough, in one hoarse and boisterous, in the other hoarse and 
frequent at first, but rare and smothered towards the end ; the 
voice, in one hoarse, but never scarcely whispering, and if so, only 
during the height, in the other hoarse at first, and soon perma- 
nently whispering or entirely lost ; the cry, in one hoarse and 
stridulous only at the moment of the paroxysm, in the other per- 
manently so ; the respiration, in one stridulous and difficult only 
during the paroxysm, and in the interval perfectly natural, in the 
other, at first natural, becoming by degrees permanently stridulous, 
and attended by the most violent dyspnoea and orthopnoea, with 
remarkable prolongation of the expiration ; the fever, in one very 
slight and generally observed only during the nocturnal paroxysm, 
in the other much more considerable and permanent ; and, lastly, 
the duration, in one seldom more than two or three days, in the 
other rarely less than six, and very often eight or ten days. M. 
Trousseau states that the hoarse, sounding, croupal cough, is not 
a sign of the presence of exudation in the larynx, but rather of its 
absence ; but, on the contrary, " when the cough, croupal at first, 
becomes less and less frequent, and ends with being nearly inso- 
norous with suffocation, there is true croup, that is to say with 



DIAGNOSIS PROGNOSIS. 



59 



plastic exudation in the larynx." This is precisely my own ex- 
perience. The rare, insonorous cough of M. Trousseau, is the 
condition which I have expressed by the term smothered. 

In order to render the diagnosis still clearer, I add the following 
table, which is altered from one given by Rilliet and Barthez. 



Spasmodic Laryngitis. 

Begins with coryza, and hoarse 
cough, or more frequently by a sudden 
attack of suffocation in the night. 
Fauces natural, or merely slight red- 
ness, as in simple angina. 



After the paroxysm, the child seems 
well ; the fever disappears, or is very 
slight. Voice natural or only slightly 
hoarse ; not whispering. 

If the paroxysm returns, it is during 
the following night, and it is less se- 
vere ; the hoarseness disappears ; the 
cough becomes loose and catarrhal. 

Duration seldom more than three 
days. 



Very rarely fatal. 



PsEUDO-MEMBRANOUS LARYNGITIS. 

In epidemic form, begins as pseudo- 
membranous angina. In sporadic 
form, invasion of slight hoarseness for 
a day or two. There is fever, increase 
of the hoarseness, with hoarse, croupal 
cough ; in half the cases, pharyngeal 
exudation, and a little later paroxysms 
of suffocation. 

The fever continues ; stridulous re- 
spiration ; prolonged and difficult ex- 
piration; cough hoarse and smothered ; 
voice hoarse and whispering. 

The dyspnoea and suffocation in- 
crease; the voice and cough are smo- 
thered or extinguished ; stridulous re- 
spiration persists. 

Duration seldom less than five or 
six. The hoarseness continues for 
several weeks. 

Fatal in the majority of the cases. 



It may be confounded also with laryngismus stridulus, and 
with simple laryngitis. The signs by which it is to be distin- 
guished, will be stated in the articles on those diseases. 

Prognosis. — Spasmodic laryngitis is very rarely a fatal disease. It 
has already been stated that of 30 cases of which I have a record, 
and of a considerable number of which I have no notes, not one 
died ; while M. Guersent makes a similar statement in regard to 
upwards of a hundred cases. That it does sometimes terminate 
fatally, however, there can be no doubt. This is the opinion Rilliet 
and Barthez have arrived at, after careful study of the subject. 
These authors quote in proof of it, amongst others, two cases 
from the work of Jurine, in one of which an autopsy was made, 



60 SPASMODIC LARYNGITIS. 

and no false membrane discovered. Copland {Loc. cit.) remarks 
that in the few cases of the more purely spasmodic forms that he 
has had an opportunity of examining, an adhesive glairy fluid, 
with patches of vascularity on the epiglottis and larynx, and a 
similar fluid in the large bronchi, were the only alterations 
observed. 

The favourable symptoms in the disease are : diminished vio- 
lence of the paroxysms ; clear and natural, or merely hoarse 
voice ; loose, catarrhal cough ; disappearance of the fever ; and 
absence of disposition to returns of the disease, or its return in a 
milder form each time. Unfavourable symptoms are : obstinate 
continuance of the paroxysm in spite of the usual remedies ; re- 
turns of the paroxysm after the third night, especially if their 
violence increase rather than diminish ; severe nausea or vomiting ; 
feeble, soft pulse ; and weakness of the voice, with other signs of 
exhaustion, even though the paroxysm may have ceased. 

Treatment. — Guersent {Loc. cit. p. 367-368) states that demulcent 
and mucilaginous drinks, with stimulating manuluvia and pediluvia 
are the principal means that ought to be employed in the treatment 
of spasmodic laryngitis, or pseudo-croup. He proscribes the use 
of emetics and leeches as unnecessary in most cases, and is of 
opinion that they have come into general use in the management 
of the disease, in consequence of its having been generally con- 
founded with true croup. In a paper on croup by my father, Dr. 
Charles D. Meigs, {Med. Exam., voL i. p. 399,) may be found the 
following statement in regard to the spasmodic variety : " The 
croup sound often ceases entirely, and never returns, after the 
exhibition of a small quantity of ipecacuanha, or any other emetic 
substance, even when no emesis is produced." He says in another 
place that, " a foot bath with mustard, and an emetic of ipecacu- 
anha, is in general all that is necessary for the cure." 

My own experience in regard to the treatment is contained in 
the following remarks. 

Emetics. — The great majority of cases will recover perfectly 
well under the use of emetics alone, or in combination with warm 
baths and revulsives. In cases attended with violent dyspnoea, 
hoarse cough, and loud stridulous respiration, the emetic should be 



TREATMENT. 61 

given until it produces a full effect. In milder cases, in which 
there is merely loud croupal cough, with an occasional stridulous 
sound, nauseating doses alone will generally suffice. Of the 30 
cases observed by myself, this was the only treatment employed 
in 29, with the exception of some mild revulsive to the neck, a 
mustard pediluvium, and occasionally a warm bath. 

The most suitable emetic is, as a general rule, ipecacuanha. 
The best preparation for children is* the syrup, of which from 
twenty to thirty drops may be given to those two years of age, to 
be repeated every ten or twenty minutes until vomiting is produced, 
or until the paroxysm is relieved. In very violent cases, the Sy- 
rupus Scillse Compositus, w r hich is more active in its effects in con- 
sequence of the tartar emetic which it contains, might be preferable; 
about twenty drops of this may be given, and repeated every ten or 
fifteen minutes, until vomiting or the resolution of the paroxysm is 
obtained ; but, in its employment, care should always be observed 
not to continue it for too long a time, lest it produce the injurious 
effects of tartar emetic. When the dyspnoea is very urgent, or 
when other means fail to produce emesis, I have found nothing so 
effectual as the powdered alum, in doses of a teaspoonful mixed 
with honey or molasses. (See treatment of pseudo-membranous 
laryngitis^) 

A simple and good method of treating the paroxysm is that 
recommended by my father, in the paper referred to. It is to 
direct a small teaspoonful of powdered ipecacuanha to be dif- 
fused in a wineglassful of water, and given in doses of a tea- 
spoonful of the mixture every ten, fifteen, or twenty minutes, 
according to the urgency of the symptoms. This is a plan of 
treatment often resorted to by parents in this community, where 
the disease is so common, and so well understood, that there are 
few mothers who have several children, and who have had some 
little experience, who do not know how to treat a nocturnal attack 
of spasmodic laryngitis. 

After the paroxysm is relieved, it is a good plan to direct five 
or ten drops of the ipecacuanha syrup to be given every two or 
three hours during the following day ; or, if the child seem per- 
fectly well in the morning, we may begin with these doses in the 

6 



62 SPASMODIC LARYNGITIS. 

middle of the day, and continue them until bed-time. By this 
method, the recurrence of the paroxysm during the second night 
may, I think, often be prevented, and the cough is rendered free 
and loose much sooner than when the disorder is left to pursue its 
natural course. 

Baths. — The warm bath is a very prompt and useful remedy in 
the disease. In all very violent cases, it ought to be resorted to 
immediately. It should be used also whenever the emetic fails to 
relieve the urgency of the symptoms, and in cases attended with 
much disturbance of the circulation. The temperature of the water 
ought to be about 96° of Fahrenheit, when the child is first im- 
mersed, to be raised gradually by the addition of hot water, to 
100° or 102°. The child may remain in the bath from ten to 
twenty minutes. 

Bloodletting. — Depletion can rarely be necessary in spasmo- 
dic croup. The only cases which would call for it are those 
in which the symptoms tend to assume the features of the grave 
form of simple laryngitis, or of pseudo-membranous croup. Under 
such circumstances the method of treatment would be the same 
as that proper for those affections, to the descriptions of which the 
reader is referred for further information. 

In one case only of the 30 that came under my observation 
was any form of depletion resorted to. That occurred in a girl, 
six months old, who was leeched in front of the larynx, because 
the action of an emetic and the use of the warm bath had failed 
to relieve the paroxysm. The child was quite well ofi the follow- 
ing day. 

Revulsives. — The only revulsives that it is necessary to em- 
ploy, are mustard pediluvia, or mustard poultices applied to the 
interscapular space; and even these are often needless if the 
emetic be given. Blisters, which are recommended by some of 
the French writers, can only be proper, it seems to me, when the 
symptoms resemble those of grave simple laryngitis, or of true 
croup. 

Purgatives are required only when constipation is present, or 
when there is fever on the second and third days, showing a 
considerable amount of laryngeal inflammation. Under the latter 



HYGIENIC AND PROPHYLACTIC TREATMENT. 63 

circumstances, some mild remedy of this class may be resorted 
to with a view to its evacuant effect. I have never had occasion 
to resort to any of the mercurials, and believe them to be unne- 
cessary. Antispasmodics and narcotics are recommended by some 
writers. They may be useful in cases occurring in children of 
highly irritable and nervous temperament, but I have uniformly 
succeeded in obtaining a cure without them. The ones generally 
employed are assafoetida, musk, or opium. 

Hygienic Treatment. — The child should be placed for the time 
in a warm room, and warmly clothed. If old enough, it ought to 
be kept as much as possible in bed during the paroxysm. If so 
young as to prefer the lap of the nurse, it should be clothed in a 
long loose wrapper in addition to its usual night-dress. It is very 
important to confine the child for one or two days after the noctur- 
nal paroxysms to a warm room, in order to prevent, if possible, an 
attack on the second or third nights. The diet must, be simple 
and of easy digestion, so long as there is any disposition to recur- 
rence of the disease. It may consist of preparations of milk, of 
bread, rice, or of thin chicken or mutton water. Meat and most 
vegetables had better be avoided, until the convalescence is fairly 
established. 

Prophylactic Treatment. — It is certain that much may be done 
by wise attention to physical education, in preventing attacks of 
the disease in children who have shown a liability to them. I 
would strongly recommend, with this view, attention to the follow- 
ing advice given by M. Guersent, who says (Loc. cit. p. 381) : 
" It is possible to a certain extent, to prevent attacks of pseudo- 
croup, by fortifying the constitutions of children, by means of 
exposing them well clothed to a dry and elastic atmosphere, parti- 
cularly if they can be kept in constant movement. But of all the 
precautions which have been found unquestionably advantageous, 
that which seems most useful is to make them sleep in well-venti- 
lated, dry, carefully closed chambers, having a south exposure, 
and always without fire. I have several times been convinced of 
the utility of this habit in families the children of which were sub- 
ject to this kind of catarrh." Dr. Eberle says that the custom 
of clothing children with their necks and the upper part of the 
breast bare, certainly renders them liable to the disease, and men- 



64 SIMPLE LARYNGITIS. 

tions the fact that in the country, and especially among the Ger- 
mans, who cover the neck and breast, croup is a very rare disease. 
During a practice of six years amongst that class of people, he 
met with only one case of the disease. 

It seems extremely probable that the custom which prevails 
extensively in this city, of dressing children between the ages 
of one and four or five years, in such a manner as to expose 
the whole of the neck and the upper half of the thorax, (for the 
dresses are made so low and loose, that half the chest is unco- 
vered), and to leave the arms bare from the shoulders, and the 
leg from the knee to the ankle, will account in some measure at 
least, for the very great frequency of the disease amongst us. I 
would, therefore, strongly recommend all who desire to preserve 
their children from the disease, to adopt the habit of dressing 
them with the same attention to comfort and health which they 
observe in regard to themselves, that is to say, to cover the body 
and limbs sufficiently to afford protection against our severe and 
fickle climate. 

If the child is pale, weak and feeble, and unable to bear ex- 
posure to the outer air, it may generally be restored to much 
better health, by careful attention to diet, and by the steady and 
long-continued use of some tonic remedy. The diet ought to 
consist of bread and milk, and of meat and the simpler vegetables, 
as potatoes and rice. The tonic most generally suitable is qui- 
nine, of which a grain may be given in pill or solution, twice or 
three times a day, while at dinner or lunch, or both, the child 
should be made to drink from a dessert to a tablespoonful of port 
wine, mixed with water. This method ought to be steadily perse- 
vered in for from three to six weeks or longer. 



ARTICLE IV. 

SIMPLE LARYNGITIS. 

Definition ; frequency ; forms. — This disease consists of simple 
erythematous inflammation of the mucous membrane of the larynx, 



CAUSES — ANATOMICAL LESIONS. 65 

sometimes attended with ulceration, but unaccompanied by exudation 
of false membrane. The frequency of the disease, during infancy 
and childhood, is very considerable, so much so that not a winter 
passes without my meeting with a good many well-marked cases. 
I shall describe two forms of the disease, the mild and the grave. 

Predisposing causes. — The disease occurs at all periods of child- 
hood, but seems to be more frequent under than over five years of 
age. Of 48 well-marked primary cases that I have met with, 39 
occurred in children under, and only 9 in those over that age. 
Of the former class, 10 of the children were under 1 year, 12 be- 
tween 1 and 2, 9 beween 2 and 3, 4 between 3 and 4, and 4 between 
4 and 5. Rilliet and Barthez state, however, that grave primary 
cases are most apt to occur after the age of five years. The only 
three grave cases that I have seen, occurred between the ages of 
one and two years in one instance, and between five and six in 
the two others. Of the 48 cases, 29 occurred in boys, and 19 in 
girls ; which agrees with the experience of the authors just men- 
tioned. As to the influence of the seasons, it may be stated that 
it is by far most common in the fall, winter, and spring months. 

The only exciting causes of the disease which appear to have 
been ascertained with any certainty, are the action of cold, the 
positive influence of which cannot be questioned ; the inspira- 
tion of irritating substances, such as gases, smoke, powders float- 
ing in the air, etc. ; and violent efforts of crying. Rilliet and 
Barthez state that they have twice known erythematous and 
ulcerative laryngitis to follow long-continued and violent crying ; 
and Billard also cites this as a cause. I am acquainted with one 
case in which a slight attack of the disease appeared to have been 
brought on solely by loud and obstinate screaming ; but, on the 
other hand, I have known many children to scream most violently 
for a much longer time, with colic, and yet worse with earache, 
without any such effect being produced. 

The disease is very apt to occur in the course of other maladies, 
and particularly of measles, small-pox, scarlet fever, bronchitis, 
and pneumonia. 

Anatomical lesions. — The anatomical alterations may consist 
of simple inflammation of the mucous membrane, with its various 

6* 



66 SIMPLE LARYNGITIS. 

effects, or of the same changes in connexion with ulceration. 
The latter class of lesions is almost always confined to secon- 
dary cases. In the former class, the mucous membrane varies 
in colour between a deep rose and violet red, which may be either 
uniform or only in patches. In severer cases, the tissue is at 
the same time softened or roughened, and sometimes thickened. 
When redness, softening, and thickening are present, the disease 
is generally confined to certain parts, and usually to the epiglottis 
and internal portions of the vocal cords ; but when redness alone 
exists, it generally affects the whole of the larynx, and sometimes 
extends to the trachea. In cases attended with ulcerations, these 
alterations exist in connexion with what have already been de- 
scribed. The ulcerations are generally small, few in number, 
very superficial, linear in shape, and are almost always found 
upon the vocal cords. They are so slight often as to escape 
observation, unless a very careful examination is made ; and this, 
perhaps, explains the circumstance of so few persons having met 
with them in the simple, acute disease. 

Symptoms ; course ; duration. — The mild form generally 
begins with an alteration of the voice or cry. In infants the 
change in the cry alone exists, so that to detect the disease, it is 
necessary to hear the child cry. In older children the same 
alteration of the cry is present, but there is in addition a change 
of the voice, consisting of various degrees of hoarseness. These 
symptoms may be so slight as to be observed in the cry only when 
it is strong and forcible, and in the voice so as to strike only the 
ear of one accustomed to be with the child ; or they may be so 
marked as to be heard in the faintest cry that is uttered, and in 
the voice so as to be evident in a moment to the most careless ob- 
server ; or there may be complete aphonia. They are often inter- 
mittent in this form, and are generally most marked in the after 
part of the day and during the night. Simultaneously, or very soon 
after, cough occurs. This is generally hoarse and rough, and early 
in the attack, dry ; at a later period it usually becomes loose, and 
as this occurs loses its character of hoarseness. The frequency of 
the cough is variable, but usually moderate; as a general rule it 
is most frequent in the evening, and early in the morning, parti- 



SYMPTOMS. 67 

cularly in infants and young children. The disease is almost 
always preceded and attended with some coryza, which, in the 
early stage, is marked by sneezing and slight incrustations about 
the nostrils, and at a later period, by mucous and sero-mucous dis- 
charges. The respiration remains natural, except that it is some- 
times nasal, and sometimes a little accelerated. There is rarely 
any fever, or it is slight, and occurs only at night. There is no 
pain in the larynx. In some cases, the hoarseness of the cry, 
voice, or cough scarcely exists,' or is but slightly marked, and the 
only symptoms are dry, hard, teasing, and paroxysmal cough, 
which, from its sound, evidently proceeds from the larynx, and 
resembles very much that produced by the tickling of a foreign 
body in the throat. This form of the complaint is very common 
in our city, and, as it occurs chiefly in infants and young children, 
is particularly troublesome at night, by keeping the child awake. 
It is apt to run on for two, three or four weeks, or even longer, 
occasioning much trouble to the parents ; the attack always ter- 
minates favourably, unless it runs into the severe form. 

The grave form may begin as such, or result from a sudden 
aggravation of the mild form. In either case it begins with hoarse, 
frequent cough, difficult respiration, restlessness, and more or less 
violent fever. Pain in the larynx, which often exists in adults, 
is rarely complained of by children, except those over six or 
seven years of age. As the case progresses, the symptoms either 
continue as they have just been described for a few days, and 
then gradually subside, or rapidly assume dangerous and frightful 
characters, similar to those of pseudo-membranous laryngitis or 
true croup. The respiration becomes very frequent and difficult, 
and, after a time, attended with the stridulous sound which accom- 
panies obstruction of the glottis ; the cough is hoarse, dry, and 
croupal ; there is little or no expectoration ; the voice grows more 
and more hoarse ; the fever continues, but the pulse becomes rapid 
and small ; the dyspnoea is very great, and all the symptoms indi- 
cate threatened asphyxia. If no favourable change takes place, 
the dyspnoea becomes suffocation ; the cough is rare and short ; 
the voice is a mere whisper, or is lost entirely ; the pulse be- 
comes small, extremely rapid, and then imperceptible; #ie counte- 



68 SIMPLE LARYNGITIS. 

nance, at first livid and congested, assumes a pale, cadaveric ap- 
pearance ; the features are contracted ; the child becomes coma- 
tose or delirious, and death occurs from slow asphyxia, or some- 
times in an attack of general convulsions. 

In favourable cases, on the contrary, the dyspnoea, and espe- 
cially the stridulous sound, diminish ; the cough becomes less 
hoarse, loose, and loses its croupal character; expectoration of 
mucous sputa takes place in older children, whilst in younger, the 
loose gurgling sound produced by the discharge of the sputa into 
the fauces, is heard at the termination of each cough ; the voice 
becomes clearer and stronger ; the fever diminishes ; the child 
regains its spirits and disposition to be amused ; and soon all 
dangerous symptoms have disappeared, and the recovery is esta- 
blished. 

In nearly all the cases that have come under my observation, I 
have found, upon examining the fauces, more or less decided in- 
flammation of the tonsils, soft palate, and pharynx. In cases 
following a rather chronic course, from two to four or six weeks, 
which are rarely accompanied by fever or hoarseness, except at 
the invasion, and sometimes in the evening, the pharyngeal mu- 
cous membrane presented a roughened, thickened appearance, 
and the tonsils and uvula were more or less enlarged and tume- 
fied. 

The duration of the disease varies according to its form and 
the circumstances under which it occurs. The mild form, when 
primary, lasts from a few days to one or two weeks, and when it 
becomes chronic, as I have known to happen in several instances, 
has lasted from two to four or six weeks. The grave primary 
form lasts usually from seven to eight days, but sometimes runs 
its course in from three to five, and in one instance proved fatal 
in twenty-four hours. The duration of secondary cases depends, 
of course, upon that of the disease during which they occur. 

Diagnosis. — The diagnosis of the mild form of the disease is 
very easy. The hoarseness of the cry, voice, and cough, the 
redness of the mucous membrane of the pharynx, and the ab- 
sence of general symptoms, will distinguish it from any other 
affection. •In somewhat severer cases of this form, in which the 



DIAGNOSIS. 69 

cough is more frequent and harassing, the general symptoms 
more strongly marked, and the respiration somewhat hurried and 
oppressed, they may at first view present the appearances of bron- 
chitis or pneumonia. The absence of the physical signs of these 
affections, will show at once by negative evidence, the true nature 
of the case. 

The only real difficulty in the diagnosis is the distinction be- 
tween the grave form, and pseudo-membranous laryngitis or true 
croup unconnected with angina ; and this, it would appear from 
all evidence, cannot in some cases be made with absolute cer- 
tainty. The only certain and undoubted sign by which to dis- 
tinguish them, is the presence of false membranes in the ex- 
pectoration. The existence of this symptom is proof positive of 
pseudo-membranous disease, but its absence is no proof that the 
case must be one of simple inflammation ; for, even though the 
membrane has been exuded in large quantities within the larynx, 
it is not always thrown off by the effort of coughing or vomiting. 
To show the difficulty of the diagnosis, I will cite the case quoted by 
M. Valleix (Loc. cit. t. i. p. 21 1 ) from M. Hache, of a child supposed 
to be labouring under true croup, who was sent to the Children's 
Hospital in Paris, in order to have the operation of tracheotomy 
performed. The absence of false membrane in the expectoration, 
and a slight remainder of clearness of the voice, occasioned the 
suspension of the operation. The child died, and no pseudo-mem- 
brane whatever was found in the larynx. The only lesions were 
moderate redness of the mucous membrane, without tumefaction, 
and without narrowing of the glottis ; so that the fatal termination 
must be ascribed to spasmodic constriction of the glottis, or to 
tumefaction of that part which had disappeared after death. 

Nevertheless, though the diagnosis is difficult, it can generally 
be made out with considerable certainty by attention to the follow- 
ing points. The pseudo-membranous form of the disease is often 
preceded or accompanied by the presence of false membranes 
in the fauces, which is not the case in simple laryngitis ; the 
symptoms of invasion of the former disease are less acute than 
those of the latter, the fever being less violent, and the restless- 
ness and irritability less marked, than is usual in the simple affec- 



70 SIMPLE LARYNGITIS. 

tion, in which the general symptoms are severe from the first. 
The hoarseness of the voice and cough follow a different course 
in the two diseases ; the progress of these symptoms being 
slow and gradual in the membranous, and much more rapid in 
the simple form. The fever is violent throughout the attack in 
the simple inflammatory disease, whilst in the other form it sel- 
dom reaches a high degree of intensity. Lastly, the presence 
of portions of false membrane in the expectoration, in connexion 
with the laryngeal symptoms, affords positive proof of the exist- 
ence of true croup. 

In some cases, in which there is little or no hoarseness of the 
voice or cough, the symptoms strongly resemble the early stage 
of hooping-cough. I have met with five instances, in which it 
was difficult not to believe for two and three weeks, that the attack 
was really one of that disease. In one of these the resemblance 
was so close, that for several days there was a distinct hoop 
during the fit of coughing, and vomiting at the close of the pa- 
roxysm. The grounds for deciding that the case alluded to was 
not pertussis were, the facts that the attack came on like laryn- 
gitis, after measles, and that the paroxysms occurred only at 
night. In the other cases a correct diagnosis was arrived at only 
by attention to the state of the fauces, which are almost always 
more or less inflamed and thickened in laryngitis, whilst they are 
not so in pertussis, and by watching the progress of the sickness. 

Prognosis. — The prognosis is always favourable in the mild 
form of the disease. I have never known of a fatal in- 
stance. The grave form is, on the contrary, exceedingly dan- 
gerous. It is impossible, in consequence of the uncertainty 
of the diagnosis between it and the pseudo-membranous dis- 
ease, and because of the few well-authenticated cases on 
record, to estimate the degree of danger with accuracy. It is, 
however, frequently fatal. Great imminence of danger is shown 
by high intensity of the stridulous sound, especially as heard in 
the expiration ; by great severity of the dyspncea or suffocation ; 
by lividity or extreme paleness of the face ; by smallness and 
rapidity of the pulse ; by coldness of the extremities/; and by de- 
lirium or convulsions. 



TREATMENT. 71 

The three cases of the grave form that came under my notice 
recovered. t 

Treatment. — The treatment of the mild form ought to be very- 
simple. Seclusion in a warm room, careful management of the 
clothing, slight reduction of the diet if there be any fever what- 
ever, a pediluvium at night of simple water, or of water contain- 
ing a little mustard, the application of some slightly stimulating 
liniment to the front of the neck and throat twice a day, and the 
occasional internal administration of some gentle expectorant and 
anodyne dose, constitute all that is necessary in the great majority 
of cases of this kind. The best internal remedies are a few 
drops of syrup of ipecacuanha with paregoric, laudanum, or 
solution of morphia, given every evening as the child is put. to 
bed, or occasionally through the day also, if the cough is trouble- 
some. A combination of syrup of seneka with that of ipeca- 
cuanha, will often be found very serviceable. 

In the more chronic and tedious cases, the use of carbonate of 
potash or alum, as recommended in the article on hooping-cough, 
has succeeded in my hands, after expectorants and anodynes had 
entirely failed. In two cases in which all these remedies had failed 
to do good, I succeeded by touching the fauces at first twice, and af- 
terwards once a day, with a solution of nitrate of silver of from five 
to ten grains to the ounce. The pencil should be pushed low into 
the pharynx, in order to apply the wash as near as possible to the 
margin of the glottis. The only treatment used in connexion 
with this, was the administration of a small dose of anodyne at 
night, and careful regulation of the hygiene of the patient. 

The grave form of simple laryngitis demands, on account of 
the rapidity of its progress, and its dangerous character, a prompt 
and active treatment. The antiphlogistic system ought to be 
resorted to from the first, in its full force. The remedies most to 
be depended on are bloodletting, calomel, and emetics. 

Bloodletting is recommended by all writers. It should always 
be resorted to unless contra-indicated by great feebleness of con- 
stitution, either congenital or acquired as the result of previous 
sickness. Venesection is preferable to leeching whenever it can 
be performed. The quantity of blood to be drawn must depend 



72 SIMPLE LARYNGITIS. 

x of course on the age and strength of the child. From four to six 
ounces may be taken from a hearty child of four years of age. 
If no visible impression be made upon the disease in six or twelve 
hours, as much more ought to be drawn either by a repetition of 
the venesection, or by leeching the throat. Should the symptoms 
not yield at all in the course of twelve or thirty-six hours after 
the second detraction of blood, I would not hesitate, did the pulse 
continue full and strong, and the child not appear very much ex- 
hausted, to abstract three or four more ounces. 

Depletion was employed in the three cases seen by myself. In 
one, the subject of which was a girl between five and six years of 
age, the dyspnoea and stridulous respiration, with hoarseness of 
the voice and cough, continued for thirty-six hours, and were not 
relieved until the child had been twice bled from the arm to the 
amount of four ounces each time, and once leeched over the 
larynx. This case presented in fact, most of the features of true 
croup. In another, in a girl of the same age, venesection to four 
ounces was employed after the symptoms had refused to yield to 
full vomiting by hive syrup. The third case was that of a boy 
between one and two years old, who was bled to three ounces. 

Calomel ought to be resorted to as soon as the real nature of 
the attack is ascertained. Its powerful sedative action upon the cir- 
culatory and nervous systems, and its specific influence upon local 
inflammations attended with increased proportion of the fibrinous 
element of the blood, as well as experience, indicate the propriety 
of its employment in this disease. A large dose, about four or 
five grains, may be given at first, in order to procure its purgative 
action, after which smaller doses, from half a grain to two grains 
every two hours, should be administered with a view of obtaining 
the aplastic influence of the remedy upon the blood. The last- 
named doses ought to be continued for one, two, or three days, or 
until the violence of the attack is evidently abating. When found 
to operate too much upon the bowels, a small quantity of opium 
must be combined with it to prevent that effect. 

Emetics are of great importance in the treatment, though less 
so perhaps than in true croup, in which it is essential to cause the 
rejection of the false membrane which obstructs the larynx. Yet 



TREATMENT. 73 

they are exceedingly useful, and sometimes indispensable, in 
assisting to expel the viscid mucus secreted within the larynx, and 
in relaxing, for a time at least, the spasmodic constriction of the 
glottis, which plays an important part in the production of the dis- 
tressing dyspnoea and suffocation of the disease. They act proba- 
bly also by lessening immediately, or through their influence on the 
circulatory and nervous systems, the inflammation of the larynx. 
They should be used once or twice, or oftener in the day, accord- 
ing to the degree of dyspnoea, and the effects they produce. For 
their choice and mode of administration, the reader is referred to 
the article on true croup. 

Purgatives are required merely to keep the bowels soluble ; 
they should be repeated as may be necessary throughout the dis- 
ease. The most suitable are castor oil, rhubarb, magnesia, or 
small doses of the powder of jalap combined with calomel. 

Expectorants are useful after the violence of the disease has 
been moderated by more energetic remedies. They may consist 
of small doses of ipecacuanha, of antimonial wine and sweet 
spirits of nitre, fractional doses of tartar emetic, decoction of 
seneka, snake-root, Coxe's Hive Syrup, or carbonate of potash. 

Opiates are often necessary and serviceable in calming exces- 
sive restlessness, and allaying the violence of the suffocative 
attacks, which depend, in part at least, as has been stated, on 
spasm of the glottis. The most suitable are Dover's powder, 
or some other preparation of opium, or small doses of belladonna, 
or hyoscyamus. 

A warm bath at 97° or 98°, employed once or twice a day, 
and continued for a period of ten or fifteen minutes, often assists 
greatly in lessening the sufferings of the child, in calming rest- 
lessness, and in moderating heat of skin and violence of the cir- 
culation, when the latter symptoms are strongly marked. The 
same effects may often be obtained by the use of counter-irri- 
tants, as sinapisms, mustard poultices, mustard foot-baths, etc. 
Blisters are of doubtful propriety in most cases. Nevertheless, I 
believe that I once saw good effects from the application of a small 
one over the larynx and trachea. 

7 






CHAPTER II. 

DISEASES OF THE LUNGS AND PLEURA, 

ARTICLE I. 

PNEUMONIA. 

Definition ; synonymes ; frequency ; forms. — The term pneu- 
monia is now, by universal consent, applied only to inflammation 
of the parenchymatous structure of the lungs. It is often called, 
in this country, catarrh-fever, lung-fever, or inflammation of the 
lungs. 

It is one of the most frequent, and therefore, one of the most 
important of the acute diseases of childhood. It is extremely pro- 
bable that a great majority of the cases, which for years past have 
been called, in Philadelphia, catarrh-fever, are in fact lobular or 
lobar pneumonia. Dr. West, in a paper on the pneumonia of 
children {Brit, and For. Med. Rev. April, 1843), informs us that 
the English tables of mortality show pneumonia to be the cause of 
a larger number of deaths in childhood, than any other disease, 
with the exception of the exanthemata. From the third report of 
the registrar-general, he quotes the facts, that of all the deaths in 
the metropolitan districts under fifteen years of age, 13*6 per cent, 
were from pneumonia, 13*0 per cent, from convulsions, and 5*4 
per cent, from hydrocephalus. He obtained nearly similar results 
from an examination of the returns from Manchester, Liverpool, 
and Birmingham. In the Philadelphia bills of mortality, the dis- 
tinction between pneumonia and bronchitis is so imperfect, that it 
is impossible to obtain data, on which to found an exact standard 
of the relative frequency of pneumonia and other diseases. It 
appears, however, not to be so fatal here as in England, since of 
26,510 deaths under fifteen years of age in this city, during the 



CAUSES. 75 

ten years preceding 1845, only 2764, or 10*4 per cent., occur- 
red from pneumonia and bronchitis combined. {Condieh Dis. oj 
Children, 2d ed. note, page 88.) 

I shall describe two forms of the disease, the lobular and lobar, 
the former of which is also designated broncho-pneumonia. Au- 
thors describe another form, to which the term vesicular is given, 
and Rilliet and Barthez refer to one which they call carnification. 

Predisposing causes. — It is generally believed that pneumonia 
is most apt to occur in the course of other affections. This is cer- 
tainly true in regard to the disease as it prevails in hospitals, and 
probably amongst the poorer classes of society also. Rilliet and 
Barthez state that of 245 cases observed by themselves, only 58, 
or very little more than a fourth, occurred in children previously 
in good health. The proportion of secondary cases is smaller in 
private practice, since of 51 that I have seen, 30, or more than 
half, occurred in children in good health. Age forms a strong 
predisposing influence. Of the 245 cases above quoted, 172 oc- 
curred under 5 years of age. Dr. West (Loc. cit.), says, that dur- 
ing the first five years of life, the cases of pneumonia were in the 
proportion of 10-3 per cent, to the total of diseases, while in the 
succeeding five years, they were in the proportion only of 1*3 per 
cent. It is most prevalent during the season of greatest activity 
of the first dentition, that is, from the 6th to the 18th month. 

Sex. — A larger number of cases occur in boys than girls. The 
excess is little more, however, than may be accounted for by the 
preponderance of male over female children. 

Constitution.— -It is doubtful whether con^ tution has much or 
any influence upon the liability to the disea -\ Dr. West says 
that weak health is not a predisposing cause according to his ex- 
perience. I am convinced that I have met with it as often in 
strong and vigorous children as in those of more delicate con- 
stitution. 

Season. — The disease is most prevalent during the winter 
months. According to the third report of the registrar-general of 
England, the greatest mortality under fifteen years of age takes 
place in December. 



76 PNEUMONIA. 

Previous diseases. — It is apt to occur as a complication of all 
the diseases of children, and most frequently in measles, pertussis, 
typhoid fever, enteritis, and bilious remittent fever. I have met 
with three cases in the course of the latter disease. 

Bronchitis. — Some writers of high authority have advanced the 
opinion that lobular pneumonia is always the consequence of a 
precedent bronchitis. This is denied by Rilliet and Barthez, who 
say " it is incontestable that lobular pneumonia may exist in chil- 
dren without bronchitis." They agree, however, in the opinion 
that the form of broncho-pneumonia is much more frequent than 
simple lobular pneumonia. Other predisposing causes are general 
debility from previous diseases ; prolonged dorsal decubitus ; the 
breathing of a vitiated atmosphere, especially that of hospitals ; 
neglect of cleanliness, and other bad hygienic conditions. 

Exciting causes. — The continued action of some of the predis- 
posing causes must be regarded as the exciting cause in the ma- 
jority of the cases. External violence, as a severe fall, or blow 
upon the chest, will sometimes act as an exciting cause. The 
action of cold is almost always alleged to be the immediate cause 
of the attack. M. Grisolle states that it is impossible to determine 
the exciting cause in more than a fourth of the cases, and that in 
nearly all of those it is cold. 

Anatomical lesions. — Lobular pneumonia. — By the term lo- 
bular pneumonia, is meant the form of inflammation which attacks 
one or more lobules of the lung, the others remaining healthy. Like 
lobar pneumonia it presents three stages, congestion, hepatization, 
and suppuration. In the first stage, the appearances are as follows : 
when the lung is cut into the surface is seen to be marbled with 
spots of a reddish or grayish rose colour, which are more or less dis- 
tinctly limited, rather less resisting than the neighbouring portions, 
and which float when thrown on water. When squeezed they 
exude a frothy, bloody fluid, and crepitate under the finger. 

In the second stage, the lung is usually soft and flaccid exter- 
nally, and of a more or less deep rose-gray colour ; it presents 
here and there circumscribed spots, which are prominent, solid 
under the finger, do not collapse when the thorax is opened like the 
surrounding tissue, and are of a purple-red colour. These spots, 



ANATOMICAL LESIONS. 77 

which are usually circular, though sometimes elongated in shape, 
are most common on the posterior surface of the lung, but may 
sometimes be seen throughout the organ. In some cases they 
appear to be absent, and the lung presents externally a healthy 
appearance, but, on pressure with the ringers, they may be felt in 
the form of nodosities, at a greater or less depth from the surface. 
On cutting into the lung, it is found marbled with spots of a 
rose-gray and violet-red colour, of which the exterior ones cor- 
respond to the red points seen on the outer surface. These spots, 
both those on the surface, and those in the centre of the lung, 
form hardened masses, presenting the characters of ordinary 
pneumonic inflammation ; they are smooth when cut into, gra- 
nulated when torn, easily penetrated by the finger, and do not 
swim when thrown upon water. When squeezed, the hardened 
tissue crepitates but little, or not at all ; its outer portions furnish 
a frothy, sanious fluid, while the centre of the mass contains a 
red and bloody fluid, which, like that of lobar pneumonia, is not 
frothy. 

The third stage presents the following appearances : the inflamed 
portions are of a yellowish, grayish-yellow, or simply grayish co- 
lour, caused by the infiltration of pus into the parenchyma ; the 
tissue is very friable, and pressure causes the exudation of a puru- 
lent fluid. When the pus is equally diffused through the diseased 
portions, so as to produce an uniform gray colour, they present 
nearly the same appearances as the surrounding healthy tissue, so 
that a careless examination might easily lead to a mistake as to 
the nature of the fatal lesion. The error may be avoided by an 
attentive examination, which would show that some of the lobules 
project above the cut surface of the lung ; that the vesicles of those 
lobules are not collapsed as are those of the surrounding parts, and 
that they yield a purulent, and not a serous fluid, when squeezed 
between the fingers. 

Lobular pneumonia has been divided by recent authors into two 
varieties, the 'partial and generalized. In the former, the number 
of inflamed lobules is small in proportion to those which retain their 
natural characters, and they are consequently thinly disseminated 
through the healthy portions of the lung ; while in the latter, much 

7* 



78 PNEUMONIA. 

the greater portion of the affected lobe is diseased, leaving only a 
few healthy lobules scattered here and there. The morbid appear- 
ances are the same in both forms, except as regards their extent, 
which is so great in the generalized as to cause it to present many 
of the features of lobar pneumonia. Of the two forms the partial is 
much more common than the generalized. In the immense majo- 
rity of cases, lobular pneumonia is double; Of 203 autopsies of 
this form made by Rilliet and Barthez, the inflammation was con- 
fined to one lung only in 5. The generalized form is infinitely 
more common in the lower than in the upper lobe, and is most 
frequent on the left side. 

It is not uncommon to meet with abscesses as an accompaniment 
of lobular inflammation. The authors referred to found them 
in 26 out of 203, and Dr. West in 2 out of 11 autopsies. They 
are rare, however, according to M. Bouchut (Malad. des Nou- 
veaux-nes, p. 318), under the age of two years. They occur as 
a result of the third stage of the disease, so that in the same lung 
may be observed hepatized lobules in the first, second, and third 
stages, and abscesses. The cavities of the abscesses are generally 
circular, sometimes oval, and measure from half a line to three- 
quarters of an inch in diameter. Sometimes the abscess is mul- 
tilocular, each of the purulent cavities being partially separated 
from its neighbour, by a wall of hepatized tissue. They are found 
in various portions of the lung, but seem disposed generally to 
approach the surface of the organ. When the latter event hap- 
pens, adhesive inflammation between the pleura pulmonalis and 
costalis usually takes place ; but should this fail to occur, the ab- 
scess ruptures into the pleural sac, and produces pneumothorax. 
Rilliet and Barthez have met with this accident twice in their post- 
mortem examinations, and report another case in which the child 
recovered. I have met with one case of pneumothorax which oc- 
curred during an attack of secondary pneumonia, complicating 
bilious remittent fever. The boy, who was eleven years old, re- 
covered perfectly, after a desperate illness. 

The number of the abscesses is exceedingly variable. Some- 
times there is but one, or they may be so numerous as to make it 
impossible to count them ; but the latter condition is very rare. It 



ANATOMICAL LESIONS. 79 

is much more common to meet with them in one lung only than 
in both, and in the left than in the right. They would seem to be 
most frequent between the ages of two and six years. 

Lobar Pneumonia. — The anatomical characters of this form 
are the same in children over a year and a half old as in adults, 
and it is, therefore, unnecessary to occupy our time with descrip- 
tions which may be found in any standard work on practice of 
medicine. Under the age just mentioned, the anatomical lesions 
are not the same as in adults, but resemble very closely those of 
generalized lobular pneumonia, so that it is often difficult to dis- 
tinguish one from the other. The affected lobe is never inflamed 
throughout, but presents outside of the indurated portions, lobules 
which retain their normal appearances, while even in the inflamed 
part of the lung, may be seen lobules in a less advanced state of 
change than those around. 

Lobar pneumonia is generally confined to one lung, and occurs 
more frequently on the right than on the left side, and at the base 
than at the summit of the lung. Pneumonia of the upper lobe is 
more common on the left than on the right side. Of 84 autopsies 
of lobar pneumonia, made by Rilliet and Barthez, the disease was 
double in 9 ; confined to the right side in 48, and to the left in 27. 
Of the 75 cases in which the pneumonia was single, it was seated 
in the lower lobe in 48, and in the upper in 27. Of the 27 cases 
of pneumonia of the upper lobe, 23 were on the right, and 4 on 
the left side. 

It is important to determine the relative frequency of the 
two forms of the disease. The authors just quoted, report 245 
cases of pneumonia, of which 161 were lobular, and 84 lobar, 
showing a great excess of the former. Dr. West, on the con- 
trary, is of opinion that the lobular form is not so much more 
frequent than the lobar at least in London, as some persons are 
disposed to think, for of 37 cases that he has observed, 22 were 
of the lobar, 11 only of the lobular, and 4 of the vesicular form. 
According to my own experience, the lobular form is much more 
frequent than the lobar, since of 51 cases of pneumonia that I have 
seen, 38 were of the former, and only 13 of the latter form. 

Lobular pneumonia generally occurs in children under six years 



80 PNEUMONIA. 

of age, while the lobar form is more frequent after that period. Ne- 
vertheless, the lobular form is not uncommon after the age men- 
tioned, as is proved by the fact that of 203 cases in which autop- 
sies were made by Rilliet and Barthez, 43 occurred in children 
between 6 and 15 years of age. Nor is lobar pneumonia confined 
to children over 6 years of age, as was thought by Gerhard and 
Rufz, since of 29 cases reported by Dr. West, 19 occurred under 
5, and 10 under 2 years of age. Gerhard, Rilliet and Barthez, 
and West, all agree that the lobular form is much more frequent 
as a secondary than as an idiopathic affection. Of 161 cases ob- 
served by Rilliet and Barthez, 158 were secondary ; while of 11 
cases reported by Dr. West, 5 followed hooping cough, 1 mea- 
sles, and though the remaining 5 are said to have been idiopathic, 
the bronchi were found to be either greatly injected, or filled with 
secretions. Dr. Gerhard, in his second paper (Am. Journ. Med. 
Set., November, 1834, p. 106) says, "the lesion known by 
the name of pneumonia of young children, is, therefore, not simi- 
lar to the idiopathic inflammation of the lungs, but is a mere 
secondary lesion occurring during the course of numerous affec- 
tions of childhood, especially bronchitis, measles, and chronic diar- 
rhoea, and should be described as the lobular induration of the 
lungs." If, however, bronchitis, which by some persons is held 
to be an integral portion of lobular pneumonia, were not taken 
into consideration, the latter would be entitled to rank as a pri- 
mary affection in a much larger proportion of the cases. The 
great preponderance of secondary over primary cases of lobular 
pneumonia, does not seem to hold good in private practice, at 
least if we regard bronchitis as an essential part of the dis- 
ease, and not as constituting a primary affection, in the course of 
which pneumonia occurs as a secondary one. Taking this view 
of the subject, I find that of 38 cases that have come under my 
observation, all attended with more or less bronchitis, 26 were pri- 
mary, and only 12 secondary. 

The lobar form of pneumonia, is much more frequently a pri- 
mary affection than the lobular, since of 84 cases observed by 
Rilliet and Barthez, 55 were primary, and only 29 secondary. 
This does not agree exactly with my experience in private prac- 



COMPLICATIONS. 81 

tice, as of 13 cases of this form that I have seen, only 5 were 
primary, and 8 secondary. 

Complications. — Bronchitis exists to a greater or less extent 
in most of the cases. The inflammation varies from simple in- 
creased vascularity with augmented mucous secretion, to intense 
congestion with purulent or pseudo-membranous secretions. It is 
most marked and most constant in the lobular form. The exces- 
sive secretion, especially that of pus and pseudo-membrane, is 
generally found in the same form. The inflammation usually 
attacks the smaller bronchia, and in a considerable number of 
cases, is accompanied by dilatation of those tubes. Dr. West 
met with this alteration in 11 cases. When slight, it was limited 
to the smaller bronchi, but when more extensive, implicated the 
larger ones likewise. It always presented the tubular form, and 
was most marked in the cases supervening upon pertussis. It is 
very rare in lobar pneumonia. 

Pleurisy is a frequent complication, occurring in about a fourth 
of the cases of the lobular, and in half those of the lobar form. 

Emphysema is another common complication. It generally 
occupies the upper part of the lung, or its free edge, and is found 
most strongly developed in the lung which presents the greatest 
amount of inflammation, or in both, when both are diseased. Its 
degree depends upon the extent of the pulmonary inflammation and 
bronchitis, and the severity of the dyspnoea. The vesicular form 
is very much more frequent than the interlobular. 

Symptoms; sketch of the disease; course; duration. — In order 
to present a faithful account of the disease, a general sketch of the 
symptoms will first be given, after which the most important ones 
will be considered separately under the head of particular symp- 
toms, so that the reader may first obtain a notion of the course 
of the disease, and then become intimately acquainted with its 
details and peculiarities, by reference to the remarks on each par- 
ticular symptom. 

Pneumonia almost always begins in infants and children at the 
breast like simple catarrh. The child is restless, uneasy, peevish, 
easily made to cry, indisposed to take the breast as usual, and after a 



82 PNEUMONIA. 

short time, is attacked with fever, cough, and acceleration of the re- 
spiration. Auscultation reveals mucous and sub-crepitant rhonchus 
in both lungs. Percussion yields only negative results. If the dis- 
ease progresses, the child becomes exceedingly restless, takes the 
breast with difficulty, and often starts back from it with a loud cry 
as though in pain. The skin becomes very hot, the pulse frequent, 
the respiration rapid and anxious, and the cough more frequent. 
Mucous, sub-crepitant, and sometimes crepitant rhonchus can be 
heard on both sides, and after a time bronchial respiration and 
resonance of the cry. At this period, the percussion is often dull 
or flat over the seat of disease. If the child recovers, thexough 
diminishes in frequency and force, and becomes loose ; the rest- 
lessness subsides ; appetite returns ; the fever disappears, and the 
physical signs gradually cease to be heard. If, on the contrary, 
the case is to prove fatal, the respiration becomes more difficult, 
and often slower ; the fever continues with exacerbations and re- 
missions ; the child is exceedingly restless ; the surface becomes 
pale and cold ; and death occurs from asphyxia. 

In older children, it begins with violent fever, increased fre- 
quency of breathing in all the cases, pain in the side in some, and 
short, dry cough. Auscultation, practised very early in the dis- 
ease, reveals crepitant or sub-crepitant rhonchus, and sometimes 
bronchial respiration, confined to one side, and usually to the base 
of the lung, in the lobar form ; and general sub-crepitant rhonchus, 
and in rare cases, bronchial expiration, in the lobular form. Vo- 
miting sometimes occurs on the first day. There is acute thirst, 
and the appetite is entirely lost ; there is generally a good deal of 
restlessness in older children, often drowsiness in younger, and in 
some few cases, convulsions. As the case proceeds, the fever in- 
creases, and the extent over which the bronchial respiration is heard 
augments, whilst the rales diminish in abundance. The dyspnoea 
increases ; the alse nasi are widely dilated ; the respiration some- 
times becomes unequal and jerking ; the cough is frequent, short, 
dry, and often painful, as shown by the child's crying at each 
cough ; and the countenance becomes anxious. Expectoration 
commences, and consists of sanguinolent and rarely of rust- 



SYMPTOMS COURSE DURATION. 83 

coloured sputa. It is usually small in quantity, and in very young 
children is entirely absent. About the fourth or fifth day, the ac- 
celeration of the pulse and respiration, and the extent of the hepa- 
tization reach their height. The bronchial murmur is loud, per- 
ceived both in the inspiration and expiration, and is accompanied 
by bronchophony and resonance of the cry, and by dulness over 
a large surface. After remaining stationary for one or two days, 
the disease begins to subside generally about the seventh or 
eighth. The heat of skin and frequency of pulse diminish ; the 
respiration becomes slower ; the ala? nasi no longer dilate ; the 
flushing of the face disappears, while its expression is more natu- 
ral; and the cough becomes loose. On auscultation, the bronchial 
respiration is found to be confined to the expiration, the voice is dif- 
fusely resonant, and an abundant sub-crepitant rhonchus is heard. 
The dulness on percussion is much less marked. A little later 
the fever ceases entirely ; the respiration assumes its natural 
rhythm ; the appetite returns ; the thirst disappears ; and the 
cough subsides very much. About the tenth or fifteenth day, 
convalescence is fairly established, though auscultation still re- 
veals prolonged expiration, and diffuse resonance of the voice. 

In unfavourable cases, death rarely occurs early in the disease ; 
but usually at some distance of time from the invasion. When 
the fatal termination occurs within the first few days, the symptoms 
assume great severity from the beginning. In this class of cases 
there is great oppression of breathing ; the pulse is rapid and very 
small ; the face pale, with a purple tint of the cheeks ; moist rales 
are heard extensively over the thorax, mingled with dry rhonchi, 
or bronchial expiration and diffuse resonance of the voice ; the 
general symptoms become more and more aggravated, and death 
occurs in three, four, or five days. When, on the contrary, the 
fatal termination occurs at a later period, the case generally pur- 
sues the course we have described up to the period of resolution. 
Instead, however, of resolution and convalescence taking place, 
the fever continues, though in a diminished degree ; the face be- 
comes pale ; emaciation occurs ; the appetite does not return ; the 
pulse remains frequent ; diarrhoea persists or comes on ; and the 



84 PNEUMONIA. 

cough, which had diminished, again becomes troublesome and 
painful. Auscultation and percussion reveal imperfect resolution, 
or an extension of the disease ; and after some weeks of strug- 
gling, the child dies in a state of emaciation and debility. 

Particular symptoms. — Physical signs. — The physical signs 
of pneumonia in children are much less certain than in adults. 
The degree of the uncertainty is very different in the two forms 
of the disease ; for, while the lobar may almost always be de- 
tected by an attentive and competent observer, it is confessedly 
often impossible for the most practised physician to distinguish 
between bronchitis and the lobular form. Thus M. Grisolle 
(Pathol. Int. t. i. p. 348) says: "Yet it is almost impossible to 
diagnosticate lobular pneumonia." M. Chomel (Diet, de Med., 
t. xxv. p. 185) says : " As to lobular or disseminated pneumonia, 
its phenomena are generally obscure, and in many cases it has 
been recognised only at the autopsy." Rilliet and Barthez, how- 
ever, whose opinion on this point is deserving of the greatest con- 
fidence, believe that it is generally possible to distinguish between 
lobular pneumonia and bronchitis, by strict attention to the phy- 
sical and rational signs combined. 

In order to practise auscultation on a young child, it should be 
placed by the mother in a sitting posture on her knee and held 
there, while the physician, by kneeling on the floor, or sitting on 
a low chair, makes the examination he deems necessary. If the 
child be old enough to take notice, it should be attracted and 
amused by some toy or glittering object. Even, however, should 
it cry violently,*rnuch valuable information is to be obtained from 
auscultation, for we can ascertain the presence or absence of 
rhonchi, and their characters, during the deep inspirations between 
the cries ; we can observe resonance of the cry and cough, and 
practise percussion. 

The physical signs of lobular pneumonia depend upon the 
proportion which the pneumonic holds to the bronchial inflamma- 
tion. When the inflamed lobules are few in number, and situated 
at a distance from each other, whilst the bronchitis is extensive, 
the physical signs of the latter affection obscure entirely those 
of the former ; and it becomes impossible to ascertain by auscul- 



PHYSICAL SIGNS. 85 

tation or percussion, the existence of the pneumonic inflammation. 
We are compelled under these conditions, to depend exclusively 
on the rational symptoms. But, when the number of inflamed 
lobules is more considerable, and they are consequently situated 
nearer together, they occasion induration of the lung, which gives 
rise to certain stethoscopic phenomena, which will betray to the 
attentive observer the presence of the pneumonic inflammation. 
These phenomena are mucous or sub-crepitant rhonchus, pro- 
longed expiration, rude respiration, and resonance of the cry and 
cough. The sub-crepitant rhonchus is an extremely important 
sign, especially in children under the age of five years. It is ge- 
nerally heard on both sides behind, and most distinctly over the in- 
ferior portions of the thorax. It is often the only stethoscopic sign 
of lobular pneumonia during the whole course of the disease. It 
frequently follows the mucous rhonchus, and when this is the case, 
and especially when associated with prolonged expiration, with 
rude or bronchial respiration, heard here and there, we may be 
certain of the existence of lobular pneumonia. If to the above 
signs are added dulness on percussion, diminution of the sub- 
crepitant rhonchus, crepitant rhonchus, and bronchial respiration 
during inspiration and expiration, it becomes certain that the 
disease is running into the lobar form. When lobular pneumonia 
pursues an acute course, the signs of hepatization rarely appear 
before the third day, and generally somewhere between the third 
and eighth. When, on the contrary, it goes on more slowly, the 
first signs of pulmonary inflammation do not occur until a much 
later period. The resolution of the inflammation is much more 
tardy in this than in the lobar form. 

The physical signs of lobar pneumonia are crepitant or sub- 
crepitant rhonchus, feeble respiration, bronchial inspiration, bron- 
chophony, resonance of the cry and cough, and dulness on per- 
cussion. They are, in fact, the same in the great majority of 
cases as in adults. Under five years of age, this form begins, 
usually, with sub-crepitant rhonchus, while after that period, the 
earliest stethoscopic signs are crepitant rhonchus, or feeble re- 
spiration. The bronchial respiration makes its appearance soon 
after the sub-crepitant or crepitant rhonchus, is heard first in the 

8 



86 PNEUMONIA. 

expiration, and then in both inspiration and expiration, and is ac- 
companied by bronchophony, resonance of the cry and cough, and 
dulness on percussion. 

These alterations of the auscultatory phenomena are confined to 
one side, in the great majority of cases, and are best observed 
over the posterior inferior portion of the lung. Rilliet and Barthez 
state that they have never known the bronchial respiration to 
disappear, in favourable cases, before the fifth day, and in 
the majority not before the seventh, eighth, or ninth ; whilst in 
fatal cases, it continued to the moment of death. Its persistence 
is always a highly unfavourable symptom in very young children, 
whilst in those who are older, as in adults, it sometimes remains 
for several days or weeks, though the general symptoms have en- 
tirely disappeared. Dr. West regards bronchial respiration as a 
very grave sign, since out of 20 cases in which he noted it, 1 1 
proved fatal. 

It may now be stated in recapitulation, that in children under 
five or six years of age, hepatization of the lung is indicated by 
sub-crepitant rhonchus appearing subsequently to mucous rhonchus, 
or associated with it ; by bronchial respiration heard first in ex- 
piration, and afterwards both in inspiration and expiration ; by 
resonance of the cry, voice, or cough ; by crepitant rhonchus in 
rare cases ; and by more or less marked dulness on percussion. 
In general these signs exist on both sides, and are confined to the 
middle and inferior portions of the thorax behind. 

In children over five or six years of age, on the contrary, the 
signs are the same as in adults, with the exception of the expecto- 
ration, which is very often, though not always, absent. They are 
feeble respiration ; crepitant rhonchus ; bronchial respiration ; bron- 
chophony ; resonance of the cough ; and dull or flat percussion, 
confined in by far the greater number of cases to one lung, and to 
the inferior portion of that lung behind. 

Rational symptoms. — Cough is stated to be invariably present, 
except in children within the month, in whom it is sometimes, but 
very rarely absent. At all other ages, it is nearly a constant, and 
therefore most important symptom. It is dry at first, and not very 
frequent, but in one or two days becomes more frequent, often 



RATIONAL SYMPTOMS. 87 

very troublesome, and from dry and harsh, is more or less 
humid and loose. It continues until the disease moderates, 
lasting generally from nine to sixteen days. In fatal cases it 
usually persists to the last. In infants it is not very frequent, 
occurs in short paroxysms, and in fatal cases often ceases one or 
two days before death. Rilliet and Barthez remark that in pneu- 
monia of the upper lobes, it has a peculiar character. It is little, 
short, smothered as it were, or piercing, teasing or slightly hoarse. 
I will merely add that cough is sometimes scarcely noticeable 
in cases which simulate hydrocephalus, during the early part 
of the attack. In the case of a child between three and four 
months old, there was absolutely no cough whatever during the 
first six days. On the sixth day, with a respiration of 100 in the 
minute, with somnolence and occasional vomiting, no cough could 
be detected either by the mother, nurse, or myself, though I saw 
the child frequently. On the seventh, the respiration being at 96, 
a little, short, dry cough was heard occasionally, and on the 
eighth, the respiration having fallen to 63, the cough was decided 
and perceptibly loose, and slight coryza had made its appearance. 
In three other cases the cough was so slight in the early stages of 
the disease, during the continuance of the cerebral symptoms, as 
not to have been noticed unless particularly inquired after. Later 
in the attack, after three, four, or five days, and as the cerebral 
symptoms moderated, the cough became frequent and loose, and 
the pneumonic symptoms pursued their regular course. 

Expectoration is almost invariably absent under five years of 
age. Rilliet and Barthez, and Gerhard, have never observed rust- 
coloured sputa under the age mentioned. In older children there 
is sometimes, though not very often, voluntary expectoration. 
Even in them, however, the sputa seldom present the character- 
istic rust-colour and viscidity observed in adults, but consist 
simply of mucus tinged with blood, or of whitish, brownish, vis- 
cous or non-viscous phlegm. I once, however, saw a child three 
and a half years old, voluntarily expectorate viscid mucus, tinged 
copiously with blood ; and I have a patient under my charge at 
the present moment, seven years old, with lobar pneumonia super- 
vening upon pertussis, who expectorates freely a tenacious mucus, 



88 PNEUMONIA. 

sometimes streaked or dotted with blood, sometimes brownish, 
and at other times rust-coloured. 

Valleix mentions a whitish or sanguinolent viscous froth, as 
sometimes escaping from the mouth of new-born children labour- 
ing under the disease. I have never met with this symptom, but 
know of one case of a child within the month, who, during an 
attack of pneumonia, vomited mucus tinged with blood. The 
child died, and presented the lesions of pneumonia. The nipples 
of the mother were perfectly healthy, so that the blood could not 
have been sucked by the child from them, but must have been the 
sputa which had been swallowed, after being coughed into the 
fauces. 

Tt is scarcely necessary to say that the absence of expectoration 
is only seeming, for children undoubtedly reject the sputa into the 
fauces, and then swallow them. 

Thoracic pain. — It is impossible to ascertain the presence of 
this symptom with certainty, prior to the age at which children 
talk, and very often not for some time after, as they refuse, or do 
not know how to describe their sensations. After the age of four 
or five years, it is often present, and frequently complained of. 
Indeed I am disposed to believe that it exists in most of the cases 
at all ages, from the fact that the act of coughing is so generally 
accompanied or followed by a cry like that produced by pain from 
other causes. I have so often remarked this disposition to cry 
after coughing, that I always ask the question, in the case of a 
young child, whether the cough is followed by crying, or by a 
momentary change in the expression of the features, like that 
occasioned by pain. In one case particularly, of a child twenty 
months old, labouring under lobular pneumonia, which had become 
lobar on one side, the movements during coughing were very 
peculiar. The patient always inclined the body strongly towards 
the side chiefly affected, forcibly stretched out the arm of that side, 
and cried violently. The pain generally comes on at the onset of 
the disease, is seated in the affected side, and is aggravated by 
coughing, and sometimes by the decubitus and percussion. 

The respiration is always quickened, except where the consti- 
tution of the patient has been greatly deteriorated by long and 



RATIONAL SYMPTOMS. 89 

severe illness or other causes, under which circumstances it re- 
mains at the normal rate, or is very slightly accelerated. This 
symptom usually dates from the invasion, and soon the breathing 
rises as high as 40, 50, and 60 in the minute, in older children ; 
and from 60 to 80 in the younger. It is more rapid commonly in 
the lobular, than in the lobar form ; in the former, I have often 
counted it at 60, 70, and 80, while in the latter, it has seldom gone 
over 40 or 50. In some rare cases of the lobular form it rises as 
high as 100 in the minute. In favourable cases, the acceleration 
subsides usually about the seventh, eighth, or ninth days. In most 
of the cases the breathing is even and regular, while in others it 
is short, abdominal, uneven, and jerking. When the dyspnoea is 
very great in a young child, the nostrils dilate widely, the mouth 
remains open, and its angles are drawn downwards and out- 
wards ; the last of these symptoms is almost a fatal one. Some- 
times the rhythm of the function is changed, so that it begins 
with a sudden, active, and moaning expiration, followed by the 
inspiration, after which comes the interval of rest. Rilliet and 
Barthez state that unequal, jerking respiration occurs almost ex- 
clusively in cases of inflammation of the upper lobes. 

Physiognomy. — The face is almost invariably flushed. The 
colour, at first scarlet, becomes after a day or two deeper and 
darker, and in severe cases assumes a livid red tint. I have no- 
ticed in extensive lobular pneumonia, in addition to the deep red 
tint, a peculiar glazed appearance of the skin, which looks as 
though it had been varnished, while the edges of the flush are dis- 
tinct and abrupt. The lips are generally deeply coloured, simul- 
taneously with the face. The flush commonly subsides about the 
same time, or a little before the diminution of the rate of the re- 
spiration. In fatal cases, the face is apt to lose its colour and 
become pale and sallow, as the unfavourable symptoms become 
more and more marked. The pallor of the face is most striking 
in severe and fatal cases occurring in infants ; the face is blanched, 
and the features pinched. 

The expression of the face is one of anxiety and oppression in 
the early stage ; in very severe cases, or those about to terminate 
unfavourably, the features become drawn and contracted. 

8* 



90 PNEUMONIA. 

Fever exists in all the idiopathic cases. The pulse, at all ages, 
is rarely under 120 from the first to the sixth or seventh day ; in 
the youngest children it rises as high as 140, 160, and even 180 ; 
while in those who are older, it is seldom above 140. In favour- 
able cases it diminishes about the fifth, sixth, or seventh day. In 
fatal cases, it is apt to diminish at the same period, but soon be- 
comes more frequent and continues so to the end. 

The skin is hot in the beginning, and continues so until the 
disease subsides. The heat is intense in severe, but not so great 
in milder cases. 

The nervous system shows more or less marked symptoms of 
disorder. There is restlessness, peevishness, and irritability during 
the day, which increase towards evening. As the night advances 
the child becomes still more restless ; infants will not sleep except 
in the arms, and wake crying or fretting every few minutes or 
hours ; older children sleep uneasily, talk in their sleep, or start 
and cry out, and are often delirious. In some instances, the irri- 
tability is most distressing, both to the child and those around. 
The child is constantly fretting and whining ; it wants its play- 
things, but will not touch them ; food, but rejects it ; and slaps and 
scolds at everything about it. Convulsions sometimes occur at the 
invasion. They last an uncertain length of time, and are usually 
followed by insensibility, from which the child wakes with fever, 
accelerated respiration and cough, indicating the true seat of dis- 
ease to be the lungs, and not the brain, as might at first be sup- 
posed. Rilliet and Barthez state that they have observed convul- 
sive symptoms almost exclusively in pneumonia of the upper lobe. 
I have met with convulsions in 5 out of 51 cases. In one they 
appeared at the beginning of lobular pneumonia in a child two 
months old ; it recovered. In a second, they appeared on the 
third day of lobular pneumonia, which had supervened upon per- 
tussis, in a child five months old. This also ended favourably. 
In the other three cases, they occurred at the termination, and 
were all fatal ; two of these occurred in the course of pertussis, 
and one of measles. 

Digestive organs. — Complete anorexia is generally present from 
the first ; the thirst is intense, greater probably than in almost any 



DIAGNOSIS. 91 

other affection of childhood. The tongue is moist, as a general 
rule, and covered with a whitish or yellowish fur. Vomiting and 
diarrhoea occur at the invasion of about half the cases in hospi- 
tals : in private practice, vomiting often occurs, but diarrhoea 
much less frequently. 

Diagnosis. — The pneumonia of children is most liable to be con- 
founded with bronchitis, pleurisy, and hydrocephalus. There is little 
probability that lobar pneumonia would be mistaken for bronchitis 
by any but a careless or incompetent observer ; for the presence, in 
the former, of sub-crepitant, and very often of crepitant rhonchus, 
of bronchial' respiration, bronchophony, resonance of the cry and 
cough, and dull or flat percussion, confined to one side, would 
easily distinguish it from bronchitis, which is marked by mucous 
and sibilant rales over both sides of the chest, and by a normal 
condition of the percussion. The difficulty in the differential 
diagnosis of the two diseases concerns, therefore, the lobular form 
of inflammation. The cause of the difficulty is the existence, in 
the vast majority of the cases of that form, of bronchial inflamma- 
tion, coincidental ly with that of the parenchyma of the lung. The 
degree of the difficulty will depend upon the proportion which the 
two inflammations hold to each other. If the amount of the 
pneumonic inflammation be great in proportion to the number of 
bronchia affected, as is the case in generalized lobular pneumonia, 
and where, in what we have called the partial form of the disease, 
the number of lobules inflamed is considerable, or they are placed 
close together, the difficulty is generally but slight. But when, on 
the contrary, the bronchitis is extensive in proportion to the pneu- 
monia, or the physical signs of the former disease are present in a 
high degree, it becomes impossible to do more than suspect, from 
the age of the patient, and character of the rational signs, the pre- 
sence of pneumonia. The symptoms which are most charac- 
teristic in such cases, are : resonance of the voice and cry, the 
phenomena furnished by very careful percussion ; and lastly, the 
age and circumstances under which the disease has been de- 
veloped. The two last-named conditions are very important ; if 
the child be under six years of age, and the attack secondary, it is 



92 PNEUMONIA. 

almost certain to be broncho-pneumonia; whereas, if over that 
age, and the attack primary, it is probably simple bronchitis. 

In newborn children and those at the breast, sub-crepitant 
rhonchus is the diagnostic mark of pneumonia, which, as has been 
already stated, is, at that age, almost invariably of the lobular 
form. In partial lobular pneumonia, we must depend chiefly on 
the sub-crepitant rhonchus, while in the generalized form, there is 
added to that, bronchial respiration, dulness on percussion, and in 
some very rare cases, crepitation. Add to these the violent cha- 
racter of the general symptoms, the intense dyspnoea with expira- 
tory respiration, as has been described, the play of the nostrils, 
the violent contraction of the chest, the distension of the abdomen 
at each respiration, and there can be little difficulty in the detec- 
tion of the true nature of the case. 

It has been stated that pneumonia might be confounded with 
pleurisy. This could not happen except in regard to the lobar 
form, as the abundance of humid rhonchi, and the absence of 
dulness on percussion, would prevent such a mistake in regard 
to the lobular form. The lobar form may be distinguished by 
attention to the fact that pleurisy is rare under six years of age ; 
by the greater severity of the pain, by the absence of rhonchi, by 
the effect of change of position on the sounds yielded by percus- 
sion, by the shorter duration and greater mildness of the general 
symptoms, by the entire absence or small amount of expectoration, 
and by the continued dryness of the cough in pleurisy; and, lastly, 
by the disposition on the part of pleurisy to become chronic, 
while pneumonia nearly always remains acute. 

Dr. West (Loc. cit,.,) states that pneumonia in the early stage 
is often mistaken for hydrocephalus. Since reading his paper, I 
have had several occasions to test the correctness of the asser- 
tion, and have no doubt that it is perfectly true. The vomiting, 
constipation, extreme irritability and restlessness, and complaints 
of headache occur in both, while the absence of symptoms 
to draw attention to the true seat of the disease in pneumonia, 
may readily mislead. The cough in the early stage of pneumonia 
is often very slight, and not being observed by the attendants, is 
not reported to the physician. The frequency of the respiration 



DIAGNOSIS. 93 

is overlooked, or, if noticed, is ascribed to the fever, which is sup- 
posed to depend on the cerebral inflammation. In pneumonia, 
however, the vomiting is not usually very frequent, nor very ob- 
stinate, nor are the bowels so much constipated as in hydroce- 
phalus. These variations from the ordinary symptoms of hydro- 
cephalus, minute though they be, ought to attract the notice of the 
physician, and lead him to examine the case more carefully ; when, 
in all probability, the physical signs would immediately reveal the 
pneumonia. I may mention, in illustration, that I attended a boy 
six years old, who, for three days, suffered from violent fever, and 
excruciating headache, which last was the only symptom complained 
of. There was neither cough, expectoration, nor any marked ac- 
celeration of the respiration. After three days the headache mode- 
rated, and he had slight pain in his side ; on examination, I found 
him labouring under well-marked lobar pneumonia. Another 
child, four months old, was suddenly seized with convulsions, 
followed by fever, vomiting, excessive irritability and drowsiness, 
so that I supposed the case to be one of meningitis. After the 
third day, the cerebral symptoms having moderated, and cough, 
with dyspnoea, making their appearance, I detected the exist- 
ence of extensive lobular pneumonia, of which the child died a 
few days after. In April, 1847, 1 was called to see a boy nineteen 
months old, who had been taken sick with slight fever, a little 
hoarse cough, and mild pharyngitis. After remaining in this 
condition for five days, he began to be drowsy and very irritable ; 
the surface became pale, and the extremities rather cooler than 
natural. From the sixth to the tenth day, there was great somno- 
lence, the child sleeping nearly all the time ; when waked from 
sleep, he was always exceedingly irritable and cross, scarcely 
opening his eyes, and then shutting them again immediately, to 
avoid the light, which was evidently painful. During this time he 
took scarcely any food, but little drink, and vomited several times 
freely; the bowels were moved without medicine; the surface re- 
mained very pale, and the extremities often cool ; the pulse was 
frequent and small ; the respiration perfectly regular, and there- 
fore attracted no attention ; there was no cough whatever. Under 
these circumstances, I hesitated between regarding the case as me- 



94 PNEUMONIA. 

ningitis, or hydrocephaloid disease, as described by Dr. M. Hall. 
I took the latter view, however, and treated it with small quanti- 
ties of brandy, cold to the head, and the frequent employment of 
mustard pediluvia. From the eleventh day the child began to 
improve; it would open its eyes from time to time, and look 
round for a few moments ; the face began to show a slight 
degree of colour, and the palms of the hands, which had been 
white and transparent, exhibited a tinge of the natural pink 
hue which they have in children. Observing about this time that 
the respiration was accelerated, though perfectly free and regular, 
and without cough, I counted it, and was astonished to find it 
80 in the minute. I now examined the chest carefully, and find- 
ing slight dulness on percussion with bronchial respiration, over 
the inferior half of the left side behind, immediately understood 
the nature of the case : it was one of latent pneumonia, simulating 
hydrocephalus. The child was now treated for pneumonia, and 
after an illness of twenty-seven days longer, recovered perfectly. 
As the case progressed, the rational signs of pneumonia were 
more and more apparent, the cough becoming frequent and pain- 
ful, and after a time loose, while the cerebral symptoms gradually 
disappeared. 

In addition to these cases I have met with three others, 
two in children within the year, and one in a child between 
one and two years old, which, during the early stages, re- 
sembled very closely the invasion of cerebral disease. Attention, 
however, to the rate of the respiration and the physical signs, 
and the presence of slight cough in two of them, revealed, after a 
little hesitation, the true character of the attacks. The third case, 
which occurred in the child within the year, was unattended by any 
cough during the first few days, and was, therefore, very obscure, 
until my attention was attracted by an acceleration of the respira- 
tion, when the physical signs, and at a later period, cough, ex- 
plained the real nature of the attack. I may remark, in addition, 
that in all these cases, the absence of constipation, the infrequency 
and short duration of the vomiting, and some clearness of the in- 
telligence when the child was fairly roused, though but for a few 
moments, from its state of somnolence, were other motives for 
doubting the attacks to be meningitis. 



PROGNOSIS. 95 

Dr. West also states that pneumonia is often overlooked in 
teething children, in whom the cough is called a tooth-cough, 
whilst the diarrhoea, which frequently occurs, and becomes the 
prominent symptom, is supposed to depend upon dentition, and is 
alone attended to. The diarrhoea is obstinate, and when, at last, 
the cough attracts attention, it is ascribed to phthisis, and the physi- 
cian is astonished to find at the autopsy purulent infiltration of the 
lungs, but no tubercles, and no disease of the intestines. The 
diagnosis is to be correctly made, under such circumstances, only 
by careful physical examination. 

Prognosis. ^-It may be stated in general terms, that pneumonia 
is dangerous in proportion to the earliness of the age at which it 
occurs and the form of the attack, whether primary or secondary. 
Lobular pneumonia, for the reason that it prevails almost entirely 
amongst children under five or six years of age, is much more 
dangerous than the lobar form, which occurs after that age. Of 
12 cases of lobular pneumonia under one year, that I have seen, 
5 were fatal. Of the 12 cases, 8 were primary, of which 3 
died, and 4 secondary, of which 2 died. Of 17 cases of the 
same form, occurring between the ages of one and two years, 
only 3 were fatal. Of the 17, 11 were primary, all of which 
recovered, whilst of 6 secondary cases, 3 died. Again : of 9 
cases of lobular pneumonia between 2 and 9 years of age, none 
died; of these, 7 were primary, and 2 secondary. Lastly, of 13 
cases of the lobar form, only 2 of which occurred under three 
years of age, and the remainder between the ages of 4 and 10, 
all recovered. Of these, only 5 were primary. 

In hospitals, and whenever the disease occurs under bad 
hygienic conditions, as amongst the poor, the prognosis is very 
unfavourable. Thus, of 128 cases in new-born children ob- 
served by MM. Valleix and Vernois, in the Foundling's Hospital 
at Paris, 127 died; while, according to M. Bouchut, of 55 cases 
between the ages of a few days and two years, observed at the 
Necker Hospital, 33 died ; and lastly, of 61 cases between the 
ages of two and fifteen years, observed by M. Barrier, at the 
Children's Hospital, 48 died. It will be observed, that of 51 cases 
observed by myself in private practice, 8 were fatal. 



96 PNEUMONIA. 

We may conclude, therefore, that pneumonia under two years 
of age is always dangerous, and that when secondary during 
that age, very much more dangerous than when primary ; that 
primary pneumonia, whether lobular or lobar, between the ages of 
2 and 5 years, will terminate favourably in the great majority of 
cases in private practice; and that when the disease attacks 
children between 6 and 15 years of age, the termination is nearly 
always in health. 

The following are some of the most unfavourable symptoms of 
the disease : convulsions ; small, weak pulse ; extreme rapidity of 
the respiration ; persistence of the bronchial respiration in young 
children (of 20 cases in which it was noted by Dr. West, 11 
died) ; incomplete resolution of the disease within the ordinary 
period ; excessive and obstinate diarrhoea ; cerebral symptoms ; 
great emaciation; greatly altered physiognomy; excessive irritabi- 
lity ; and a yellowish tint of the skin. M. Trousseau regards as 
an unfavourable symptom the occurrence of swelling of the veins 
of the hands, which he supposes to depend on an obstacle to the 
function of hasmatosis. 

Treatment. — The treatment of pneumonia has been studied 
with the greatest care during the last several years. The re- 
searches of Louis, Grisolle, Rilliet and Barthez, and West, have 
given a completeness and certainty to this part of our subject, not 
possessed in regard to any other malady. I shall confine my re- 
marks to the remedies which are now generally acknowledged to 
be most important, leaving those of doubtful value unnoticed. 

Bloodletting. — It is very generally conceded at the present time, 
that the loss of blood, whether by venesection, leeching, or cupping, 
exerts a more powerful influence upon pneumonia than any other 
remedy. Its effects are to relieve, and m some cases, to remove, 
with very great rapidity, the general symptoms. It reduces the 
frequency and force of the circulation, moderates the heat of skin, 
calms the restlessness, and relieves the dyspnoea, thoracic pain, 
and headache. It is very doubtful, however, whether it shortens 
the duration of the disease, or exerts much influence on the extent 
of the hepatization, — at least such is the conclusion of several of 
the French observers. Dr. West awards to it the first place in 



TREATMENT. 97 

importance amongst the remedies for the disease ; and with him I 
entirely agree, though fully aware of the fact, that whilst the gene- 
ral symptoms are mitigated by bloodletting in the manner above 
described, the local disease is apt to run its usual course of several 
days. I once saw a boy, five years of age, with lobar pneumonia 
of the left side, from whom eight ounces of blood had been taken 
by venesection and leeches, walking about the room apparently 
well, after a week's sickness, in whose case there was still present 
over the inflamed lung, dulness of percussion, bronchial respira- 
tion, and crepitant rhonchus ; and I have now under my charge a 
girl four years of age, who, on the seventh day of the attack, after 
being leeched on the fifth, had a respiration of twenty, a pulse of 
ninety, and a cool natural skin — who was, in fact, entirely convale- 
scent ; in whom, nevertheless, there was dulness of percussion over 
the lower half of the right lung, with bronchophony and bronchial 
respiration. 

The amount and manner of the depletion must depend on the 
age of the patient and form of the pneumonia. It is usually re- 
commended to make use of leeches and cups in children under two 
years of age, and of venesection after that age. The quantity of 
blood to be drawn must depend on the age and strength of the pa- 
tient, and violence of the attack. At the age of two or three years, 
and in idiopathic cases, about four ounces may be taken from the 
arm at once. Should this fail to produce some relief to the symp- 
toms in twelve hours, the bleeding may be repeated ; or better 
still, some scarified cups or leeches applied over the seat of the 
disease. I feel quite sure that I have seen more benefit derived 
from cups than leeches under these circumstances, and would 
therefore prefer to use them where there is nothing to prevent. It 
is a common idea that scarified cups are too painful to be applied 
to young children, but this is not the case when they are properly 
selected. The cups should be much smaller than what are used 
for adults, and the scarificator of a size to suit the cups. With 
these precautions, it will be found that the operation of cupping a 
child within the year, and still more from the age of a year up- 
wards, is less annoying to the child and more expeditious than that 
of leeching. I would, on these accounts, strongly advise coun- 

9 



98 PNEUMONIA. 

try practitioners, who often complain of the difficulty or impos- 
sibility of procuring leeches, to provide themselves with cups of a 
size suitable for children, to be used in the place of leeches. 

Whether leeches or cups be preferred after general bleeding, 
about two or three ounces of blood should be taken from over the 
inflamed portion of the lung. 

In children under two years of age, leeching, as has been 
stated, is generally preferred to venesection. I have not hesi- 
tated, however, to employ venesection in the course of the second 
year, when the symptoms have been very acute. The number of 
leeches should seldom exceed ten or twelve, which will commonly 
take about two ounces of blood. 

In cases of secondary pneumonia, depletion must be used with 
great care, as they have been found not to bear the loss of blood 
well. This is the opinion both of Rilliet and Barthez, and of Dr. 
West. It is best, therefore, in most of these cases, to employ only 
local bleeding. 

Antimony. — This remedy is well known to exert a power- 
ful influence over pneumonia. Like bloodletting, it diminishes the 
force and frequency of the circulation and relieves the oppression ; 
but like that, too, while moderating the constitutional symptoms 
and tending to keep them within safe limits, it fails to cut short or 
jugulate the inflammation. Dr. West recommends it particu- 
larly in cases preceded by catarrhal symptoms and those occur- 
ring during measles or hooping cough, and in cases of the lobar 
and idiopathic forms, where bleeding has failed to give efficient 
relief. In the first class of cases, he gives it " in doses of a 
quarter of a grain to a child of two years old, repeated every ten 
minutes till full vomiting is produced, and continued afterwards 
every two or three hours, for forty-eight or sixty hours." In the 
second class he gives the same doses every two hours for twenty- 
four hours, and thinks it " paves the way for the advantageous 
employment of mercury." When, however, the pneumonia had 
been neglected, so that the period for depletion had passed, and when 
distinct bronchial respiration was audible, he has " not found the 
large doses, recommended by the French practitioners, to produce 
beneficial results." Rilliet and Barthez give to younger children 



TREATMENT. 99 

from two to four grains, and to those who are older, as much as 
six grains of the tartar-emetic, in solution, in the twenty-four hours. 
They administer the solution in spoonful doses every half hour. If 
the first doses cause vomiting they are repeated less frequently. 
The quantity given on the first day is continued for the two, three, 
or four following days. They recommend caution, however, in the 
administration of the remedy, especially in very young children ; 
and should it produce excessive vomiting or severe diarrhoea, ad- 
vise its instant suspension. Should the state of the inflammation 
still require its administration, they employ it in very minute 
doses, and abandon it immediately should the intestinal symptoms 
return. 

For my own part, I have not found such large doses of antimony 
necessary in private practice, and I believe them to be often inju- 
rious. ■ 

The attention of the reader is requested to the following extracts 
from pages 467 and 468 of the first volume of Rilliet and Barthez. 
" One of the chief causes of gastritis and softening of the stomach in 
children has been, according to our experience, the employment 
of energetic treatment directed upon the gastro-intestinal mucous 
membrane. We refer particularly to the tartar emetic solution 
given for several days in succession. Though the doses were not 
carried to a great extent, and the quantity of the vehicle was ample, 
the disease has often occurred, thus proving the susceptibility of 
the mucous coat." They recommend great reserve in its use, " be- 
cause two-thirds of the cases of gastritis that we have observed, 
and some of the cases of softening, followed the employment of 
that remedy." They remark afterwards, however, that the gastro- 
intestinal lesions generally followed the exhibition of the anti- 
monial in secondary, while it seldom occurred in idiopathic cases 
of the disease. 

It seems to me that the facts just quoted ought to cause us to 
hesitate in the administration of antimony in the large doses 
generally recommended. My own experience inclines me to be- 
lieve that it is seldom necessary to give to children of two and 
four years old more than half a grain or a grain in the day, and 
to younger children still less. I have met with some children, and 



100 PNEUMONIA. 

in a few instances this is true of all the children of a particular 
family, who would bear only the smallest doses. I have known 
the hundredth part of a grain repeated every hour, to produce 
nausea and vomiting in children of two and four years of age. 
This very winter, I had under my charge a child two years old, 
who could take only half a drop of antimonial wine every two 
hours. 

My own practice has been to give the remedy after depletion, in 
doses of the thirtieth, fortieth, and even sixtieth parts of a grain 
every hour, to children of the age of two or three years, and 
even in this quantity it often produces vomiting or painful nausea. 
If the fever, oppression, and heat of skin, persist in the same de- 
gree after several doses, the quantity should be increased ; if, on 
the contrary, they subside, the doses ought to be diminished. In 
the cases of children over the age of three years, the dose must 
be increased according to circumstances. A very convenient and 
satisfactory mode of exhibiting antimony to children, is to give the 
vinum antimonii, combined with sweet spirits of nitre, in the doses 
of two, three, or four drops of the former, with eight or ten of the 
latter, repeated every two hours ; the proportions of the former to 
be increased or diminished as the stomach is found to tolerate it. 
To infants within the year, antimony ought to be given, it seems 
to me, with the very greatest caution. Many at that age do not 
tolerate well more than from half a drop to two drops of the wine, 
every two hours. Beyond that dose, it is very apt to produce 
exhausting nausea or diarrhoea. The use of the antimony ought 
to be persevered in until the acute symptoms have moderated, when 
it should be left off gradually. 

Before concluding my remarks upon antimony, it is proper to 
state that I am well aware of the fact that the doses recommended 
by the authors quoted above, and by many others of the highest 
authority, come at last to be tolerated by the stomach in a great 
many cases. I cannot but think, however, from personal expe- 
rience, and from the evidence adduced by many observers in regard 
to the injurious effects of such doses upon the stomach and intes- 
tines, in at least, some of the cases, that we are scarcely justified 
in resorting to them, particularly as it has been found (by myself 



TREATMENT. 101 

at least), that the disease is curable by smaller doses, in connexion 
with other means. 

Calomel. — I am induced to believe from personal experience in 
private practice, that calomel is seldom necessary in the treatment 
of pneumonia. I have found a fair proportion of the cases that 
have come under my hands to recover without a resort to it, and, 
as I deem it a violent remedy that ought to be administered only 
when really called for, I have seldom prescribed it, and when I 
have done so, it has been in one or two full doses during the acute 
stage of the malady, for the purpose of procuring its sedative and 
cathartic action. MM. Rilliet and Barthez oppose its employment 
in secondary pneumonia as injurious, and in idiopathic cases as 
unnecessary, because in the latter form, the treatment by depletion 
and antimony has succeeded very well in their hands. Dr. West, 
on the contrary, awards high praise to it as a remedy after deple- 
tion ; but as he gave it largely combined with tartar emetic, I am 
disposed to ascribe a great part of the favourable effects of the 
treatment to the antimony. Dr. West also recommends it very 
highly in cases of neglected pneumonia, after the time for depletion 
has gone by. In such cases its internal employment is often 
contra-indicated by the existence of diarrhoea ; under these con- 
ditions he uses it externally. In children of four years of age, 
he directs one drachm (of mercurial ointment I suppose), to be 
rubbed into the thighs or axillse every four hours. He says he 
has never known salivation to follow this plan, but has found the 
symptoms to diminish gradually in severity, and the solid lung to 
become once more permeable to air. Of the success of this plan 
of treatment I have had no personal experience, as such cases 
are very rare in private practice. I would, however, under these 
circumstances, prefer the employment of the iodide of potassium, 
which I have found of great service in the chronic pulmonary 
complaints of children. From half a grain to a grain of that 
remedy, dissolved in compound syrup of sarsaparilla, may be 
given three times a day, to a child three or four years old. 

Expectorants ; purgatives. — Ipecacuanha is preferable to the 
antimonial preparations in the treatment of pneumonia under 
the following circumstances : when the disease occurs in infants 

9* 



102 PNEUMONIA. 

within the year ; in. children of highly nervous temperament, or of 
feeble and delicate constitution ; in many cases of the secondary 
form; in some of those in which bronchitis is the predominant ele- 
ment of the attack ; in mild cases ; and lastly in subjects who from 
idiosyncrasy do not bear antimony well, and of such there are 
many. The most convenient preparation is the syrup, of which from 
ten to twenty drops may be given every two hours, at four years 
of age ; from five to ten drops, between one and three years ; and 
from one to three drops to infants of two or three months. It is 
useful to combine sweet spirits of nitre with the syrup, in doses 
to suit the age. In lobular pneumonia, when the child is much 
oppressed by the presence of large quantities of mucus in the 
bronchia, the operation of an emetic is often highly beneficial. 
Ipecacuanha is the most suitable remedy under these circum- 
stances, as it answers the indication perfectly well, and produces 
less exhaustion and depression than any other. Either after or 
without the emetic, I have found decided benefit in such cases 
from the administration of decoction of seneka and spiritus Min- 
dereri. For a child two years old I direct two drachms each of 
seneka and liquorice root to be boiled in a pint of water down 
to twelve ounces, and strained. A teaspoonful of this decoc- 
tion is to be given every two hours, with twenty drops of the 
spiritus Mindereri. 

A. purgative dose is useful at the beginning of the attack as a 
derivative and evacuant, but after that period, remedies of that 
class need to be used only to such an extent as to keep the bowels 
soluble. It is scarcely necessary to say that when antimony is 
employed, especially in any considerable quantity, it almost always 
supersedes the necessity of purgative medication. The patient 
ought, however, to have a stool once a day or every second day. 
At first, a dose of castor oil, a moderate quantity of magnesia or 
syrup of rhubarb, is all-sufficient. In the after-treatment of the 
attack, a repetition of the same remedies in smaller quantity, or, 
what is often better, an occasional enema, is all that is necessary. 
Violent or frequently repeated doses of purgatives are injurious 
by exhausting the patient, or by setting up gastric or intestinal 
irritation. 

External applications. — Rilliet and Barthez say that they have 



TREATMENT. 103 

never found either blisters, Burgundy pitch or tartar emetic plas- 
ters, exert the least influence upon any one of the symptoms of 
pneumonia, but that, on the contrary, they increase the fever. 
Dr. West has been led to abandon the use of blisters entirely, in 
consequence of the irritation and fever they occasion, and the dis- 
position to sloughing he has observed amongst the poor. I think 
I have observed great benefit in a few instances from the appli- 
cation of a blister, when depletion and antimony or ipecacuanha 
have failed to produce some moderation of the symptoms after four 
or five days. I have always been careful, however, even in chil- 
dren two or three years old, never to allow the blister to remain 
longer than an hour and a half or two hours. I direct it to be 
removed commonly in an hour and a half, whether the integument 
be blistered, of a scarlet colour, or unchanged. A warm bread and 
milk poultice is then used as a dressing, and rarely fails to cause 
vesication in a few hours, if it has not already occurred. Many 
times I have been told by the mother that the skin was still white 
and unchanged beneath the blister when she removed it, and yet 
the poultice has produced full vesication. Treated in this way, 
blisters cause very little irritation, and I have never known but 
one to slough in my life, which happened in a child whose skin 
had been very much irritated by frictions with amber oil and 
ammonia. 

Since the spring of 1845, however, when I was led to make 
frequent use of mustard poultices and pediluvia in the treatment 
of the bronchitis and broncho-pneumonia of measles, I have 
rarely employed blisters, but have preferred the employment 
several times a day of the remedies just indicated. Two parts 
of indian meal and one of mustard, for young children, and 
for those who are older equal proportions, are to be mixed with 
warm water, and spread thickly like a poultice on a piece of 
flannel or rag five or six inches square. This is to be covered 
with fine muslin, linen, or gauze, and applied over the back of the 
thorax. It may remain from fifteen to forty minutes, or until the 
child cries or complains or the skin is reddened. The mustard 
foot-baths may be employed at the same time with the poultices. 
These applications are useful whenever the oppression is very 



104 PNEUMONIA. 

great, and, when resorted to in the evening, often allay irritability 
and dispose the child to sleep. The number of applications to 
be made in a day must depend on the urgency of the symp- 
toms. I have employed them from once a day to every two or 
three hours. 

Tonics and stimulants are to be resorted to in cases which 
manifest undoubted signs of debility. When, therefore, the attack 
occurs in a feeble child ; when the inflammation remains unre- 
solved after depletion and other remedies, and when, as Dr. West 
says, extensive bronchial respiration persists, though the fever has 
moderated, attention must be paid to the state of the constitution, 
to the neglect of the local disease. The system must be sustained 
and strengthened in order to give it time and power to carry on 
the operations necessary for the removal of the local obstruction. 
With this view, all depleting means should be abandoned, and the 
child put upon a nutritious diet and the use of tonics and stimu- 
lants. The diet may consist of preparations of milk, of soups, 
eggs, and small quantities of meat carefully prepared. The best 
stimulants are weak brandy and water, milk punch, wine whey, 
or wine whey and arrow-root water. The most suitable tonics 
are quinine and the preparations of iron. A grain of quinine, 
suspended in a mixture of equal parts of syrup of gum and syrup 
of ginger, and given three or four times a day, has succeeded best 
in my hands. 

Opiates are sometimes necessary in cases occurring in children 
of highly nervous and irritable temperament, in the secondary and 
cachectic forms of the disease, and whenever the cough is very fre- 
quent and harassing. After the acute symptoms have moderated 
a little, an evening dose of the Dover's powder, or a few drops 
of laudanum or paregoric, with sweet spirits of nitre, are often of 
great service. 

General management. — The diet ought to be very strict in 
idiopathic cases. The child should have nothing for two or three 
days except demulcent drinks, or weak milk and water sweetened ; 
no solid food ought to be permitted. After the severity of the 
symptoms has moderated, pure milk, milk toast, or chicken water 
may be allowed; and when all fever has disappeared, the usual food 



BRONCHITIS. 105 

may be given, at first, however, in small quantity. A child at the 
breast ought not to nurse as freely as usual. At all ages, care 
should be taken to give water from time to time : very young chil- 
dren often suffer severely for want of attention to this point. I 
have seen the most violent and obstinate screaming in a child a 
year old, quieted at once by a copious draught of cold water. The 
patient should be kept closely confined in a well-ventilated room, 
with the temperature as nearly as possible between 68° and 70° F. 
A direction given by some of the French writers, and by Dr. 
Gerhard, is not to allow very young children to lie for too long a 
time in one position in bed or in the nurse's arms, as it is apt to 
produce a stasis of blood in the dependent portion of the lungs, 
and thus maintain or increase the disease. Dr. West recommends, 
whenever the inflammation has reached an advanced stage, or in- 
volved a considerable extent of the lungs, that the patient be moved 
with great care and gentleness, lest, as he has often seen occur, 
convulsions be produced. 



A R T I C L E I I. 

BRONCHITIS. 

Definition; synonymes; frequency ; forms. — The term bron- 
chitis is now universally employed to express inflammation of the 
mucous membrane of the bronchia. 

It is usually called in this country catarrh, and catarrhal fever. 
It has been stated under the head of pneumonia, that many of the 
cases known amongst us by the popular term catarrh -fever, are, in 
fact, cases of lobular pneumonia. I shall, on account of this mis- 
application of names, endeavour to draw the distinction between 
bronchitis and lobular pneumonia with great care. Bronchitis is 
not treated of either by Dewees or Underwood. Dr. Eberle con- 
founds it with pneumonia under the titles of catarrh, catarrhal 
fever, acute bronchitis, and pleuritis. 

Bronchitis is one of the most frequent of the diseases of child- 
hood. We have already seen that pneumonia causes a larger 



106 BRONCHITIS. 

proportion of deaths amongst children in London, than any other 
disease except the exanthemata. It appears from the tables 
of mortality published by Dr. Condie (Dis. of Children, note, 
page 88), that of 26,510 deaths under fifteen years of age in 
Philadelphia, during the ten years preceding 1845, 1592 were 
caused by pneumonia, and 1172 by bronchitis, and that of the 
different diseases of the respiratory organs, bronchitis was the 
most frequent after pneumonia. It is more common as a secondary 
than as an idiopathic disease. Of 115 cases observed by Rilliet 
and Barthez, only 21 were idiopathic. Of 23 cases that I have 
recorded, 11 were primary and the remaining 12 secondary. The 
diseases during the course of which it is most apt to occur, are 
pertussis and measles. 

I shall describe three forms of the disease: 1, acute bron- 
chitis of moderate severity ; 2, acute suffocative bronchitis, or 
catarrhus suffbcativus, the congestive catarrhal fever described by 
Eberle and by Dr. Joseph Parrish of this city ; 3, subacute or 
chronic bronchitis. 

Causes. — Amongst the predisposing causes of the disease, age 
is one of the most important. Rilliet and Barthez suppose it to 
be much more common in children over, than in those under five 
years of age. Of 115 cases observed by them, 37 occurred be- 
tween the ages of one and five years, and 78 between six and 
fifteen years of age. It is scarcely fair, however, to compare a 
period of nine years with one of only four, as is done in the above 
statements. Of 23 cases that I have seen in private practice, 8 
occurred between birth and two years of age ; 10 between two 
and four years ; 3 between four and six ; and 2 between six and 
ten years of age. It would seem also that the simple acute, and 
the acute suffocative forms are most common under six years of 
age, while the secondary cases occur more frequently after that 
age. The fact of its being more frequently a secondary than a 
primary affection, has already been noticed. The diseases in 
which the largest number of cases occur are measles, pertussis, 
and typhoid fever. The secondary cases are most common, of 
course, during the prevalence of the diseases whose progress they 
complicate, whilst the primary cases are most common in the cold 



CAUSES ANATOMICAL LESIONS. 107 

months of the year, and especially in the autumn and spring. 
Bronchitis is sometimes epidemic amongst children as it is amongst 
adults. 

The only exciting causes whose effects in the production of the 
disease seem clearly proved are, sudden transitions from a warm 
to a cold atmosphere, and sometimes the contrary change ; pro- 
longed exposure to cold, particularly when combined with mois- 
ture ; and the inspiration of irritating gases. 

Anatomical lesions. — Acute form. — The morbid alterations 
always exist in both lungs ; and, according to M. Bouchut, are 
most intense in the right. The appearances observed in most of 
the cases are redness, caused by injection of the minute vessels of 
the mucous and subjacent tissues, softening of the mucous mem- 
brane, which can be ascertained only in the larger bronchia, and 
sometimes a thickened, unequal, and rough appearance of the 
same membrane. Ulcerations are extremely rare. In mild cases, 
the bronchia contain a viscid, transparent, frothy, or opaque 
yellowish mucus ; in more violent cases, they are filled with a 
yellowish, yellowish-white, or whitish fluid, which is thick, not 
frothy, and mixed with pus and mucus, or with- grayish, thin, 
not frothy, and liquid pus. The fluid escapes at the open extre- 
mities of the bronchia. Portions of pseudo-membrane are some- 
times found mixed with the secretions just described, while in other 
cases, false membranes alone are present. In some instances, 
the false membrane exists in the form of patches, and in others it 
constitutes a lining to the whole extent of the bronchial ramifica- 
tions. It is usually soft and but slightly adherent, and the mucous 
membrane beneath is either very pale and of its usual consistence, 
or red, softened, and rough. The different kinds of secretion are 
commonly most abundant in the bronchia of the inferior lobes. 

In most of the severe cases, another lesion, dilatation of the 
bronchia, is also found upon examination. This change evidently 
occurs under the influence of the inflammation; it may affect 
either the length of the air-tubes, or only their extremities. In 
the former condition, the tube continues of the same size, or be- 
comes gradually larger from one of its early subdivisions, until 
it reaches the surface of the lung ; in the latter condition, a sec- 



108 BRONCHITIS. 

tion of the lung presents an areolar appearance, from the presence 
of a multitude of little rounded cavities, communicating with each 
other, and with the bronchia, of which they seem to be a con- 
tinuation. These cavities are generally central, though they are 
sometimes found upon the surface of the lung, in which case they 
are formed of the pleura, lined by the thinned membranes of the 
dilated bronchus. 

Chronic bronchitis. — The lesions just described as character- 
istic of acute bronchitis, are also met with in the chronic disease. 
The dilatation of the air vessels, however, presents different fea- 
tures. The calibre of the enlarged tube is often much greater, 
its walls are whitish and uneven and cry under the scalpel, and 
beneath the mucous lining may be seen hypertrophied transverse 
fibres. The mucous membrane itself remains smooth and polished, 
while the tissues beneath are thickened and hypertrophied. 

Symptoms ; sketch of the disease ; course ; duration. — Acute 
simple bronchitis generally begins with a moderately frequent 
cough, which, dry at first, soon becomes loose, and is neither 
paroxysmal nor painful. The expression of the face remains na- 
tural, with the exception of an appearance of slight languor. The 
pulse and respiration are but slightly accelerated ; the external 
phenomena of the latter, an important means of diagnosis in in- 
fants, remain natural ; it occurs without jerking, the rhythm con- 
tinues even and regular, and there is no violent action of the aloe 
nasi. The percussion is not modified. Auscultation reveals in 
very young children, a mixture of mucous and sibilant rales on 
both sides, which come and go, and are of short duration; in older 
children, the moist rales predominate, and commonly last several 
days. These sounds are seated in the larger bronchia. The 
temper of the child is not much changed ; the appetite is not en- 
tirely lost ; there is neither vomiting nor diarrhoea ; and the fever 
is usually slight. The disease remains nearly stationary, or in- 
creases for a variable length of time, after which the cough be- 
comes looser, and in children over five years of age, is sometimes 
attended with expectoration of frothy or yellowish mucous expec- 
toration, whilst under that age there is no expectoration. The 
fever and other symptoms, with the exception of the cough, now 



_ 



SYMPTOMS. 109 

subside ; the cough remains some days longer. The duration of 
this form is generally short; the idiopathic cases last usually from 
six to fifteen days, and more rarely from sixteen to twenty-five ; 
the duration of the secondary cases depends in great measure upon 
the nature of the diseases during which they occur. 

The acute suffocative bronchitis, or congestive catarrhal fever of 
Parrish and Eberle, and suffocative catarrh, capillary bronchitis, 
or bronchial croup of other writers, may succeed to the form just 
described, or appear as an idiopathic affection. Under either con- 
dition, the general symptoms are more threatening than in the 
preceding form. The child is much more restless, irritable, and 
cross ; violent fever soon comes on, the pulse being full and fre- 
quent, running up to 130 and 180; the face is flushed; the tongue 
moist and furred white ; the thirst acute ; and the appetite lost. 
The respiration soon quickens ; the cough, if it existed before, 
increases, and if not, soon makes its appearance, and is generally 
dry ; it occurs in short paroxysms, with or without stridulous 
sound, and after a few days, is accompanied by yellowish, or more 
rarely by pseudo-membranous expectoration. It is sometimes 
painful. The resonance on percussion is not modified. Auscul- 
tation reveals snoring or sibilant, mucous, and sometimes sub- 
crepitant rhonchi. In very young children, the vesicular murmur 
is rather more feeble than usual ; the dry rhonchi are less abun- 
dant than the moist, are observed only at times, and at other 
moments are absent : the mucous rale is very abundant, and 
varies in sound according to the size of the bubbles by the break- 
ing of which it is produced ; it is present both in the inspiration 
and expiration, but especially in the inspiration, and is heard on 
both sides of the chest. It is fugitive and irregular, disappearing 
sometimes after an effort or after coughing, to be replaced by sub- 
crepitant rale or even natural respiration, and soon after returning 
with its usual characters. The sub-crepitant rale, which is always 
present in young children, is subject to the same changes and 
irregularities as the mucous rale. 

If the disease increases, and in some instances from the begin- 
ning, the respiration is very frequent, irregular, and difficult. When 
the oppression is very great, it is accompanied by paleness or dark 

10 



110 BRONCHITIS. 

congested colour of the face, particularly after coughing ; by 
violent action of the ala3 nasi, and by coolness or coldness of the 
whole surface. The pulse becomes still more frequent, and at the 
same time small and irregular. The decubitus is dorsal, with the 
shoulders more or less elevated. If the attack is prolonged, 
irregular remissions of the symptoms occur. Towards the close 
a great change in the expression of the face takes place ; the cough 
becomes very difficult, the respiration extremely frequent, the 
pulse imperceptible ; the child is soporous or very restless ; and 
at length death closes the scene. 

The duration of this form is variable. According to Dr. 
Eberle, it seldom lasts longer than two or three days, and in very 
young infants, death sometimes occurs on the first day. M. 
Bouchut gives as the duration in children at the breast, from two 
days to a week, and states that it generally runs into lobular 
pneumonia. In older children it usually lasts from three or four 
to six or eight days, but sometimes eighteen days or more. 

Sub-acute and chronic bronchitis generally follows one of the 
acute forms of the disease. The phenomena yielded by ausculta- 
tion are very irregular both in character and degree; the fre- 
quency of the respiration, and the attacks of dyspnoea persist ; the 
cough is loose and paroxysmal ; the pulse is frequent and small ; 
evening exacerbations of fever take place ; the face, and sometimes 
the rest of the surface, are often covered with perspiration. Aus- 
cultation reveals tubal blowing, with mucous or loud sonorous 
rhonchus, which seem to indicate the presence of dilatation of the 
bronchia. Emaciation makes rapid progress ; the face is pale and 
blanched, the eyes sunken, the nostrils are covered with mucous 
or bloody crusts, and the lips ulcerated. Strength diminishes pro- 
gressively ; the appetite is lost, and the thirst acute ; colliquative 
diarrhoea appears ; and after twenty, forty, or more days, the child 
perishes in the last stage of marasmus. This form of bronchitis 
often simulates phthisis very closely, and may last for a long 
time, even several years. It rarely occurs under the age of five 
years. The expectoration consists of purulent or pseudo-mem- 
branous secretions in variable quantity. 

Particular symptoms. — Physical signs. — The dry rales are 



SYMPTOMS. Ill 

amongst the most frequent alterations of the respiratory sound in 
bronchitis. They may be sibilant or sonorous ; they seldom exist 
alone, but are accompanied by mucous rale, and diminish as the 
latter becomes more abundant. As the dry rales cease to be 
heard, they are replaced by mucous or sub-crepitant rhonchus, or 
by feebleness of the respiratory murmur. The sibilant rale is 
often heard over the whole thorax, though sometimes confined to 
the posterior portions. It is not confined to cases of inflammation 
of the larger bronchia only, but is also present in capillary bron- 
chitis. 

Humid rales. — Mucous and sub-crepitant rhonchus do not exist 
in all cases without exception, as they may be absent in such as 
are very mild. They may generally be heard on both sides be- 
hind, more rarely over the whole of the chest, and almost always 
both in inspiration and expiration. They are generally persistent, 
but are sometimes suspended for a moment and replaced by 
sibilant rhonchus, or feeble respiratory sound. Their duration is 
in proportion to that of the disease. The value of the sub-crepitant 
rale as a symptom of bronchitis depends chiefly on the age of the 
patient. In children under five years of age, who, after presenting 
the signs of bronchitis for a few days, exhibit a fine and equal sub- 
crepitant rhonchus on one or both sides behind, there is strong 
ground for suspecting the formation of pneumonia. It is not cer- 
tain that the child has pneumonia, but it is very probable, since 
acute bronchitis in very young children is almost always associated 
with pneumonia. After the age mentioned, sub-crepitant rhonchus 
is indicative only of bronchitis, unless it be heard during the course 
of some disease in which lobular pneumonia is a frequent com- 
plication, when it will be as likely to indicate broncho-pneumonia, 
as simple bronchitis. 

Feeble respiratory murmur is sometimes observed. It is not 
permanent, occurs during the interruptions of the sub-crepitant or 
sonorous rale, and does not occupy the whole extent of the thorax, 
but is limited ; it is intermittent, and is not accompanied by dimi- 
nished sonoreity. 

When dilatation of the bronchia exists to a considerable extent, 
it gives rise to bronchial or even cavernous respiration, and to 



112 BRONCHITIS. 

resonance of the voice, cry, and cough. The bronchial respira- 
tion differs from that of pneumonia by its tone, and by its inter- 
mitting. The percussion is generally sonorous. 

The physical signs above described, are not invariably present 
in bronchitis. Cases do occur, though they are very rare, in 
which auscultation fails to reveal the presence of the disease. 

Rational symptoms. — The rational symptoms are of the utmost 
importance in informing us of the severity of the attack. 

Cough generally exists from the beginning, being in mild cases 
more or less frequent, and either dry or loose ; while in severe 
cases it is frequent or very frequent, at first dry and then moist, 
and very rarely hoarse. In acute or sub-acute capillary bronchitis, 
the cough has a particular character. From the first day, it 
occurs in short paroxysms, lasting from a quarter to half a minute. 
The paroxysms vary greatly in violence, occur at irregular inter- 
vals, and generally continue without interruption to the fatal ter- 
mination, though they are sometimes replaced by simple loose 
cough a few days before that event. The cough is rarely painful, 
so long as the inflammation remains simple. Expectoration is 
never present in very young children. When it occurs in those 
over five years of age, it consists, in the mild form, of a sero- 
mucous or yellowish mucous frothy liquid. In general bronchitis, 
it is sero-mucous at first, becoming after a few days yellowish 
and more or less viscous; it is sometimes nummular, and some- 
times amorphous. 

The respiration varies in its characters according to the extent 
and violence of the disease. In mild cases, it is not much in- 
creased in frequency, being generally between 28 and 40 in the 
minute. In more violent cases, and particularly when the disease 
implicates the smaller bronchia, it becomes very frequent. The 
acceleration is slight in the beginning, but increases regularly as 
the case progresses ; thus it may be 30 at first, and rise after- 
wards to 50, 60, 80, and even 90. When not very much quick- 
ened, it remains even and regular ; when more so, it becomes 
somewhat laborious, and the movements of the chest are full and 
ample ; in severe cases, attended with much dyspnoea, it is often ir- 
regular, or assumes the characters to which M. Bouchut has applied 



SYMPTOMS. 113 

the term expiratory ; that is, the order of the movements is in- 
verted, each respiration beginning with the expiration, leaving the 
pause between the inspiration and expiration, instead of between 
the expiration and inspiration. In chronic bronchitis with copious 
purulent or pseudo-membranous expectoration, the dyspnoea is 
generally habitual. 

Fever. — The fever is slight in mild cases, the pulse rising very 
little above its natural standard. The heat is not great, and the 
febrile movement usually subsides before the termination of the 
disease. In the grave or capillary form, on the contrary, the 
pulse is always frequent, and continues to increase in rapidity as 
the disease advances. It varies between 104, 120, 160, and in 
very violent cases, rises as high as 200. Early in the attack, it is 
vibrating, rather full and regular, whilst in fatal cases, it always 
becomes small, irregular, trembling, and unequal. The skin is 
generally hot in proportion to the activity of the pulse, except 
towards the termination, when the extremities often become cool. 
It is almost always dry. In very young children it is often pale 
and cold, and covered with perspiration from the beginning. 

The expression of the face is unchanged in mild cases, but when 
the disease is violent and extensive, becomes deeply altered after a 
few days. The eyes are then surrounded by bluish rings ; the 
expression is uneasy, anxious, and sometimes, but less frequently, 
exhibits an appearance of profound exhaustion. The anxiety of 
the countenance increases with the oppression ; the alee nasi are 
dilated ; the nostrils dry or incrusted ; and the lips and face, which 
are extremely pale or momentarily congested, assume a purple tint, 
particularly after the paroxysms of cough. 

The decubitus is indifferent at first, but as the disease progresses 
the child lies with its thorax more or less elevated, or is restless 
and constantly changing its position. 

In dangerous cases there is great distress and restlessness after 
the first few days, or even from the beginning. In some instances 
the irritability and peevishness are excessive and uncontrollable, 
while in others, there is heaviness and somnolence, especially to- 
wards the termination of fatal cases. Some of the disorders 

10* 



114 .BRONCHITIS. 

of the nervous system just mentioned are present in all the grave 
cases. 

Digestive organs. — There is moderate thirst and incomplete 
anorexia when the disease is mild, but, when severe, the thirst 
is generally acute, and the appetite entirely lost. The state of the 
bowels varies. The tongue and abdomen present no special cha- 
racters in idiopathic cases. 

Diagnosis. — The mild form of bronchitis, in which the inflam- 
mation is confined to the larger bronchia, is not likely to be mis- 
taken for anything but the early stage of hooping cough. The 
diagnosis can be made only by attention to the different characters 
of the cough, which is more spasmodic and paroxysmal in per- 
tussis, by the absence of fever in that disease, and by the deve- 
lopment of the peculiar symptoms of each, as the case progresses. 
The severer forms of bronchitis, and particularly the suffocative, 
may be confounded with lobular pneumonia. In very young chil- 
dren, it is often impossible to distinguish between extensive bron- 
chitis and lobular pneumonia, the physical signs being the same 
in both. M. Bouchut states, however, that the diagnosis can be 
made in very young children, by careful attention to the external 
phenomena of respiration. He says that in generalized bron- 
chitis, the respiration is frequent, abdominal, without constriction 
of the base of the thorax, and without agitation of the nostrils ; 
while in confirmed pneumonia, on the contrary, the respiration is 
inverted as to its rhythm, and is jerking or moaning, like that of 
an adult in whom a sudden sigh is followed immediately by a 
quick inspiration ; it is in fact expiratory. 

Chronic bronchitis may be mistaken for tuberculosis of the lungs 
or of the bronchial glands. The distinction can be made only by 
careful study of the history of the case, and of the phenomena 
afforded by auscultation and percussion. 

Prognosis. — Bronchitis is a much more serious disease in 
children at the breast and those under five years of age, than 
after that period, because of the strong disposition it has to pass 
into pneumonia. For that reason it ought always, even in its 
mildest form, to be carefully watched in its symptoms and pro- 
gress, when it occurs under the age mentioned. 



PROGNOSIS TREATMENT. 115 

The acute simple form is in itself a mild affection of but little 
consequence, but requires to be watched for the reason just 
given. When, on the contrary, the disease is more extensive, 
affecting all the bronchial ramifications, and constituting the suffo- 
cative form, it is at all ages a most dangerous malady. Rilliet 
and Barthez state that all their own patients, and those of M. 
Fauvel also, died. I have seen but two well-marked primary cases 
of this kind. One occurred in a child nineteen months old in the 
month of December 1846. The child had been sick for three 
days with an attack of the mildest form of acute simple bronchitis, 
when it suddenly became alarmingly ill. The dyspnoea was ex- 
treme ; the respiration between 80 and 90 ; the face pallid, anxious, 
and suffering ; the surface cool and covered with cold perspiration ; 
the cough paroxysmal, moderately frequent, short and painful ; 
and the pulse very rapid and small. The child was satisfied only 
when resting erect in the arms of its mother, with the front of its 
chest lying upon her breast, and its head over her shoulder. There 
were abundant sibilant, mucous, and sub-crepitant rales over all 
the posterior portion of the thorax. It continued very ill with 
these symptoms for thirty-six hours, then began to mend, and in 
two days more, was convalescent. The other case occurred in a 
boy between one and two years old, and presented the same symp- 
toms, except that they were less severe. 

The symptoms indicating great danger are : increase of the 
dyspnoea, extreme anxiety, small and irregular pulse, coolness or 
coldness of the skin, with clammy sweats, much jactitation, and 
delirium, drowsiness, or coma. With such sj^mptoms, the danger 
is greater and the fatal termination more imminent in proportion 
as the child is younger, less robust, and its constitution exhausted 
by preceding or coincident disease. 

Treatment. — The acute simple disease requires, when mild, 
little other treatment than careful attention to the hygienic condi- 
tion of the patient and the administration of some mild expecto- 
rant. The child ought to be confined to an apartment with a well- 
regulated temperature, and kept quiet, either in bed or on the lap. 
The clothing ought to be warm, and yet not sufficient to produce 
free perspiration, which would expose to chilliness. The diet 



116 BRONCHITIS. 

must be simple, and may consist of some of the preparations of 
milk with bread. As an expectorant, an occasional dose of syrup 
of ipecacuanha through the day, either alone, or if the cough be 
frequent and troublesome, combined with a little paregoric, lauda- 
num, or solution of morphia, is proper and useful. The bowels 
ought to be moved once in the twenty-four hours, either naturally 
or by an enema. A warm pediluvium, with the addition of salt 
or mustard, in the evening, will generally assist to procure a quiet 
night. 

When, in the same form, the symptoms assume greater seve- 
rity, when the signs of reaction are prominent, the dyspnoea con- 
siderable, and the cough frequent and harassing, it is sometimes, 
though not always, advisable to take a little blood. In children 
under three years of age, it is best, as a general rule, to make use 
of leeches, by which from one to two ounces of blood may be 
taken from the interscapular space ; in those over that age, from 
two to four ounces may be drawn in the same way, or by vene- 
section. It seems to me, however, that the great majority of cases 
of this form of bronchitis will do perfectly well without bloodletting 
of any kind. A gentle purge ought to be given, unless the bowels 
have already been freely moved. This may consist of castor oil, 
rhubarb, magnesia, or what is a very convenient dose for children, 
half a teaspoonful of fluid extract of senna mixed with a tea- 
spoonful of spiced syrup of rhubarb. At the same time some 
febrifuge and diaphoretic may be exhibited with much advantage. 
I am in the habit of using the antimonial wine or syrup of ipe- 
cacuanha, combined with sweet spirits of nitre, as in cases of pneu- 
monia. When the fever is considerable and the patient over a 
year old, the antimonial preparation is the best ; from one to four 
drops, with five drops of sweet nitre, may be given every two 
hours. In some few children and in young infants, half a drop 
only of the wine will be borne without nausea and exhaustion. If 
the ipecacuanha be preferred, and it is generally most proper for 
children at the breast, the dose must be proportioned to the age, 
constitution, and present condition of the patient. 

If, as the case progresses, the bronchial secretions become very 
abundant and the dyspnoea severe, the proper remedy is an emetic. 



TREATMENT. 117 

This may be ipecacuanha, either in powder or syrup, the syrupus 
scillce compositus, or a teaspoonful of powdered alum, to be re- 
peated, if necessary, in ten or fifteen minutes. The latter sub- 
stance is, as I have stated under the head of croup, a very certain, 
efficient, and safe emetic. 

Great benefit may be obtained in all forms of bronchitis, from 
the more or less frequent application of mustard poultices to the 
front or back of the thorax, and from mustard pediluvia. If the 
symptoms are obstinate, a small blister over the sternum, or still 
better, the interscapular space, allowed to remain not more than 
one and a half or two hours, and then dressed with a poultice, is 
often very useful, though they should be avoided in young children 
as long as possible. 

The mercurial preparations, so much recommended by many of 
the English and by some of our own writers, appear to me to be 
very seldom really necessary in this, or indeed, in any of the 
forms of bronchitis in children. 

Rilliet and Barthez recommend, when the cough and sibilant 
rale persist after the disappearance of the febrile symptoms, the 
use of small doses of the flowers of sulphur. I have myself known 
this remedy to prove useful in such cases. About four grains 
may be given every three hours to a child four years old. 

The grave acute or capillary form of the disease must be treated 
more actively than the preceding. While the pulse remains full 
and strong, the face flushed, and the skin hot, depletion is the most 
efficient remedy. The amount of blood to be taken must depend 
on the age, constitution and present condition of the child; if over 
two years old, if of strong and robust appearance, and not reduced 
by preceding disease, from three to six ounces might be drawn 
from the arm. In younger children it is better, in general, though 
not in all cases, to employ leeches, taking within two ounces at a 
time as a common rule. I am in the habit of applying leeches, in 
the cases of children, to the interscapular space, as most conve- 
nient and most effectual, because of its proximity to the roots of the 
lungs. After the child has recovered from the immediate effects 
of the bleeding, an emetic of ipecacuanha or alum may be admi- 
nistered with great benefit ; two hours after the emetic, ^small 



118 BRONCHITIS. 

doses of antimonial wine and nitre, or fractional doses of tartar 
emetic should be prescribed, and repeated every hour or two hours. 
At the same time a mustard poultice to the thorax and a mustard 
pediluvium may be directed, and advantageously resorted to again 
in four or six hours, or, if the oppression be very great, in a shorter 
time. 

In still more severe cases, in which the dyspnoea is excessive ; 
the pulse very rapid and small ; the skin cool and pale ; the jacti- 
tation very great ; and when there is present extensive mucous and 
sub-crepitant rhonchus, the treatment recommended by Rilliet and 
Barthez, and by M. Fauvel, is the frequent employment of emetics. 
Depletion is, it seems to me, entirely contra-indicated under such 
circumstances. In one very severe instance of the kind already 
referred to, the dangerous symptoms subsided under the use of cup- 
ping, mustard poultices and pediluvia frequently renewed, and the 
internal use of decoction of seneka and spiritus Mindereri every 
hour. Six small cups, of which only two were scarified, were ap- 
plied over the back of the thorax. In another case, which occurred 
in a child eighteen months old, during an attack of measles, the 
symptoms yielded, and the eruption made its appearance, under the 
use of mustard pediluvia and poultices applied every two hours, 
and the internal use of spiritus Mindereri and sweet spirits of 
nitre. In both cases, the symptoms of exhaustion were so strongly 
marked, that I feared to employ emetics, lest they might fatally 
increase the already dangerous prostration, though the dyspnoea 
and abundant mucous and sub-crepitant rales seemed to call for 
them. If the exhaustion were to become excessive, it would be 
proper to resort to stimuli, amongst which wine whey, or weak 
brandy and water, would be the most suitable. 

Chronic bronchitis. — The most important points in the treat- 
ment of chronic cases consist in a rigorous and persevering regu- 
lation of the hygienic conditions of the patient, and in the use of 
tonic, balsamic, and expectorant remedies. The child should be 
carefully and warmly clothed ; it ought to be taken as often as 
possible into the air in fine weather, and only in fine weather ; 
and the diet should be selected with a strict view to the improve- 
ment^ the strength and vigour of the constitution. The food may 



PLEURISY. 119 

consist, if the child be of proper age, of light meats, of potatoes 
and rice, as the only vegetables, and unless there is some contra- 
indicating circumstance, of a small quantity of wine, with the mid- 
day meal. The best wine is port, of which one or two tablespoon- 
fuls may be given, in a considerable quantity of water. 

Tonics must be administered throughout the course of the dis- 
ease, or until the appetite and strength shall have improved to 
such an extent as to make them no longer necessary. The best 
is probably quinine, in the dose of a grain morning and evening, 
to be continued for several weeks ; or, the citrate of iron and 
quinine in the dose of half a grain or a grain three times a day, 
or from one to three drops of the solution of iodide of iron, used 
in the same way, may be substituted. 

In one case of chronic bronchitis, which came under my care, 
the child recovered under careful regulation of the hygiene, and 
the use of a decoction of seneka prepared by boiling a drachm 
each of seneka and liquorice roots, in a pint of water, to half 
a pint. The decoction was strained, and a large teaspoonful 
given three times a day. The remedy was used during a period 
of two months ; under its use the child grew fat and strong, and 
recovered entirely from the disease. 

Other remedies, proposed by different authors, are the various re- 
sinous preparations ; the balsams of tolu and copaiba, benzoin, and 
the sulphurous mineral waters. While these means are employed, 
it is recommended also to make use of counter-irritants. If any 
are used they ought to be such as will not produce too much in- 
flammation of the skin, as for instance weak Burgundy pitch 
plasters, daily frictions with hartshorn and sweet oil, a simple 
diachylon plaster, or very mild pustulation with croton oil. 



ARTICLE III. 

TLEURISY. 

Definition; frequency ; forms. — Pleurisy consists in inflai 
mation of the pleural serous membrane. 



120 PLEURISY. 

Idiopathic pleurisy is a very rare disease under five years, and 
especially during the first and second years of life. After the age of 
five years it becomes more frequent. Secondary pleurisy, on the 
contrary, or that which occurs in the course of other diseases, is 
common at all ages. M. Bouchut met with it in 23 out of 68 
autopsies of new-born and suckling children. Of the 23, 9 ac- 
companied acute pneumonia, 6 tubercular pneumonia, 5 entero-co- 
litis, and 3 different other diseases. This form of the affection is 
rarely detected during life, being masked by the concomitant ma- 
lady. I have met with only three idiopathic cases, two of which 
occurred between the ages of four and five, and one at seven years 
of age. 

I shall describe twp forms of the disease, the acute and chronic. 

Predisposing causes.— As to the influence of age, it has already 
been staled that idiopathic pleurisy is very rare between birth and 
five years of age. Secondary cases, on the contrary, are most 
common between the ages of one and five years. The disease is 
more frequent in boys than girls. The idiopathic form is most apt 
to occur in vigorous and hearty subjects, while the chronic and 
cachectic forms attack those who are feeble and delicate. It is 
often, as already stated, a secondary affection, occurring particu- 
larly during pneumonia, and after that disease, during rheumatism, 
scarlet fever, and Bright's disease. Season is another predisposing 
cause. It is most common during winter and spring, especially the 
latter. 

The exciting causes are very obscure in most cases. The only 
ones which seem to have been ascertained with any certainty, are 
long exposure to cold and to sudden changes of weather. It has 
been said to follow external violence. In one of the cases that 
came under my observation, the child had struck the affected side 
severely against a pointed stick on the day of the attack. 

Anatomical lesions.— ;The serous membrane may retain its na- 
tural characters, which happens in the majority of cases, or it 
may present the different appearances indicative of inflammation. 
These are more or less minute and abundant injection and punc- 
tuation, spots or patches of an ecchymotic appearance, observable 
particularly at the points where deposits of false membrane have 



ANATOMICAL LESIONS. 121 

taken place. Another change produced in the pleura by inflam- 
mation is the loss of its natural polish, which is replaced by a 
more or less granular and rough appearance. In chronic cases 
it becomes whitish or opaline in colour, and thickened. It is very 
rarely softened. 

In addition to the lesions of the pleura itself there are various dis- 
eased products of secretion which require notice. These may be 
either solid or liquid. The solid products are the false membranes 
which exist so generally in all serous inflammations. These are 
found both upon the costal and pulmonic pleura. In their recent 
state they are of variable size and thickness, being in some cases 
very soft and deposited in small points ; in others, more extensive, 
but thin like paper ; and in others again thicker (one or two lines 
in thickness), firmer, and decomposable into several layers. The 
outer layers are yellow, elastic, and soft, while the inner ones are 
red, more resisting, and marked with vascular arborizations. When 
observed some time after their formation, the false membranes 
are found to have been converted into cellular adhesions, which 
may either be very loose, or fasten the lung tightly to the costal 
pleura. The adhesions are generally, however, thin, transparent, 
and in the form of loose bridles. After a length of time, the 
false membranes come to present the appearances of true serous 
tissue, and like that, are susceptible of inflammation. 

The fluid found in the pleural cavity usually consists of trans- 
parent or turbid serum, holding albuminous fiocculi in suspension. 
Sometimes, but more rarely, it consists of purulent serum, and 
still more rarely of pure pus. The liquid generally occupies the 
lowest portion of the thoracic cavity, but is sometimes circum- 
scribed at various heights, or between the lobes of the lung, by 
abnormal adhesions, or by some part of the lung which has been 
rendered incompressible by inflammation. 

The lung presents various alterations from its healthy con- 
dition. It is pressed backwards towards its root to a greater or 
less extent. The tissue of the organ is generally found in one of 
two conditions : either hard, not crepitating, impenetrable to the 
finger, and presenting a smooth surface when cut into, a state of 
things which has been expressed by the term carnificution^ and 

11 



122 PLEURISY. 

which is a mechanical effect of pressure ; or else the lower lobe, 
which is in contact with the fluid, is large, heavy, fleshy, rather 
hard, not so easily penetrable by the finger as in simple hepatiza- 
tion, yielding under pressure only a small quantity of blood, and 
but slightly retracted towards the spinal column. The latter con- 
dition, depends in all probability on an effusion which has occurred 
after, or coincidentally with, hepatization. 

In some cases, in which the effusion is but small, or where it 
has been absorbed, the lung is found to be elastic and crepitating. 
Whatever the amount of effusion may be, it is said that the lung 
can always expand to its normal size if the fluid be absorbed. 

Pleurisy, whether complicated with pulmonic disease or not, is 
much the most frequently confined to one side. In idiopathic 
cases, it is more common on the right than left side ; when it ac- 
companies pneumonia, it is, on the contrary, more common on 
the left than right. 

Symptoms. — In describing the symptoms, I shall treat first of 
the physical, and afterwards of the rational signs and course of the 
disease. 

The physical signs are exceedingly important, as they often 
constitute, especially in young children, the only means of recog- 
nising the disease. The pleural friction sound is less important 
than some other physical signs, as it is scarcely ever heard in 
children under five years of age, and only during the absorption 
of the fluid, as a general rule, in those above that age. Bronchial 
respiration may commonly be detected from an early period in 
the attack. At first it is heard during inspiration, but afterwards 
exists both during inspiration and expiration, or in the former 
alone. In the majority of the cases it is heard over the posterior 
portion of the thorax, and upon one side only. At first it is audi- 
ble over nearly the whole height of the affected side, while later 
in the disease, it can be perceived only at the inferior angle of 
the scapula or in the interscapular space. Its duration is varia- 
ble ; it may disappear in a few days, or last for a much longer 
time. In favourable cases it is usually replaced by feeble vesicu- 
lar respiration, more rarely by friction sound, and sometimes by 
pure respiration. This sign is almost always present at all ages 



PHYSICAL SIGNS. 123 

in acute cases, but is often absent in those which are slow and 
tedious. In suckling children it is not constant, but intermits oc- 
casionally, so that it may be heard at one and not at the next 
examination. JEgophony can rarely be detected in children less 
than two years old. Under that age, there is heard instead of it 
resonance of the cry, especially in the region beneath and on a 
line with the spine of the scapula. It is intermitting like the bron- 
chial respiration. In children over two years old, segophony can 
often be distinguished by careful examination, but never, of course, 
unless the quantity of effusion is considerable. It is heard at an 
early period of the attack, and chiefly in acute cases, and must 
be sought for in the lower portion of the interscapular space, 
and the inferior dorsal region. It coexists almost invariably with 
bronchial respiration; lasts but a short time, disappearing after 
one, two, three, or four days ; and is intermitting. In older chil- 
dren, it is sometimes replaced by diffuse resonance of the voice, as 
it is by resonance of the cry in infants. 

Feebleness or absence of the respiratory murmur seldom exist 
at the beginning of acute cases, but in the sub-acute or chronic 
form are generally present from the invasion. In the latter class 
of cases feeble respiration is noticed first over the inferior portion 
of the dorsal region, but, as the effusion increases, it is heard also 
in the upper and anterior regions, and becomes more and more 
feeble, until at length no sound whatever is audible : the respira- 
tory murmur is suppressed. In acute cases, on the contrary, the 
absence of the respiratory sound is observed at variable periods of 
the attack ; when soon after the invasion, it is generally coincident 
with bronchial respiration, which, heard at first over the whole or 
inferior three-fourths of the dorsal region, becomes afterwards 
perceptible only in the interscapular space, or at the inferior angle 
of the scapula, while the respiration is feeble or absent over the 
lower portions of the lung. In very acute cases the feeble respi- 
ration remains limited to the dorsal region, and disappears after a 
few days, while in chronic cases it extends over a larger surface, 
and continues for several weeks, or even months. 

Percussion. — This means of diagnosis is very important in all 
cases of the disease accompanied by effusion of liquid, unless the 



124 PLEURISY. 

quantity is exceedingly small. When, on the contrary, the in- 
flammation results merely in the product'on of thin false mem- 
branes, percussion furnishes no useful information. 

Percussion is of no assistance, however, at the moment of in- 
vasion, as it is not until the period at which effusion takes place 
that the resonance of the thorax begins to be altered. In acute 
cases, the resonance is generally duller than natural, though 
seldom entirely dull, on the second, third, or fourth day. As the 
effusion augments, the dulness increases over the region occupied 
by the fluid, until at length all resonance ceases, and the sound is 
perfectly flat. The degree of dulness can be properly appreciated 
only by comparing the two sides together. The degree, extent, 
and duration of this sign will depend of course upon that of the 
effusion. In children as in adults, the sounds afforded by percus- 
sion vary with the position of the patient, which influences of 
course the situation of the fluid in the pleural cavity. 

In regard to the physical signs of pleuro-pneumonia, it may be 
stated that when a pleuritic effusion takes place in a child labour- 
ing under pneumonia, it happens as a general rule, that the bron- 
chial respiration occasioned by the inflammation of the lung in- 
creases in intensity, though in some few cases it is diminished or 
suppressed. Rilliet and Barthez lay down the following principle : 
" that when a pleuritic effusion occurs in a child affected ivith 
hepatization of the inferior portion of the lung, all the abnormal 
sounds tvhich ivere perceptible over the diseased point are con- 
siderably exaggerated, and the sonoreity disappears." 

Inspection of the thorax affords no assistance at the invasion of 
the disease, nor generally in acute cases which last but a short time, 
and in which the amount of effusion is small. When, however, the 
effusion is large, it may be observed upon close examination, that the 
movements of the affected side during respiration are more limited 
than those of the opposite one, and that the intercostal spaces are 
more projecting than natural, in consequence of distension by the 
fluid within. At the same time mensuration will show that the 
side on which the effusion exists is larger than the other. The 
difference may amount to a third or two-thirds of an inch. In 
acute cases, in which the quantity of liquid is small, mensuration 






RATIONAL SYMPTOMS. 125 

will of course show no difference. When the effusion is large, 
'palpation is a very important sign. The hand applied over the 
diseased side feels no vibration of its walls either during respira- 
tion, crying, or speaking. This sign exists in the cases of infants 
as well as of older children. 

Rational symptoms; course; duration. — Acute pleurisy is 
very rarely met with, as already stated, in children under six 
years of age, except as a secondary affection. In idiopathic cases 
it begins with severe pain in the side, cough, some difficulty of 
respiration, increased frequency of the pulse, loss of appetite, 
thirst, bilious vomiting, sometimes headache, and in rare instances 
delirium. The pain in the side or stitch, is almost always present 
in acute cases occurring in healthy children, while in those which 
are slight, or occur in weak and debilitated subjects, or very 
young children, it very often cannot be detected. Sometimes, 
however, its existence may be ascertained in very young children 
by tenderness of the side shown during the act of percussion. It 
is aggravated by coughing, by full inspirations, by change of posi- 
tion, and by percussion. The seat of pain is almost always in 
front ; but it may extend irregularly over the whole of one side, 
or be confined to the false ribs, or less frequently, to the neigh- 
bourhood of the nipple. The pain generally lasts from three to 
six days, though it sometimes continues longer. This symptom 
was complained of in the three cases that came under my notice. 
In one it lasted a week, and in the second only two days, though 
in both the effusion was extensive, and required several weeks for 
its absorption. In the third case, it continued for five days. In 
the last, the effusion was very slight. It was aggravated in all by 
coughing, by the act of respiration, especially when this was deep, 
and by motion. 

Cough exists in nearly all idiopathic cases, and generally from 
the onset, though sometimes not before the second or third day. 
Usually frequent and dry, it commonly retains these characters in 
acute cases, for four or six days, and then diminishes rapidly. In 
more tedious cases it continues for a longer time, but moderates in 
violence after some days. In secondary cases it has no special cha- 
racters. Cough existed in only two of the three cases seen by 

11* 



126 PLEURISY. 

myself. In one it was frequent, rather dry, and very painful for 
the first few days, after which it became looser, and though the 
inferior two-thirds of the right side were filled with effusion for a 
period of two weeks afterwards, it ceased entirely. In the other 
it was frequent, dry, very painful, so as to elicit loud complaints, 
and lasted a week, after which the child recovered with only slight 
effusion. In the third case, in which the whole of the left side was 
occupied by the effusion, there was no cough whatever ; neither 
the mother nor myself ever perceived any. 

The expectoration is very slight, or there is none. It was 
absent in the three cases referred to. 

The respiration is usually accelerated in acute cases ; but re- 
mains natural in other respects ; the dyspnoea, however, is slight 
compared with that of pneumonia. In the chronic form it is gene- 
rally regular and but little increased in frequency. The difficulty 
of breathing is commonly great in proportion to the earliness of 
the age, and to the extent and rapidity with which the effusion 
takes place. In one of the cases observed by myself, it was 
between 40 and 50 during the first two days, after which it 
fell, as the effusion took place, to 30. In the second it was 45 
at first ; at the end of a week 38 ; at the end of the third week, 
as the effusion was being absorbed, it was 28, and then gradually 
fell to 20, the natural rate. In the third it was at 60 for the first 
few days, but at the end of a week had nearly regained its natural 
condition. In the last case the effusion was very small, and the 
convalescence rapid. 

The fever is not usually very great, and seldom lasts more than 
a few days, or a week. During the first three or four days, the 
pulse rises to 110, 120, or 130, and seldom higher, after which it 
commonly falls again, so that by the end of a week it is seldom 
over 70, 80, or 90. The heat of skin is not very great in most 
instances, and generally subsides rapidly and disappears after a 
few days. In acute secondary attacks, the febrile symptoms are 
more marked as a general rule, than as has just been described, 
because of the existence of the concurrent disease. In chronic 
cases the fever sometimes assumes, after a while, the hectic type. 

The countenance presents no particular characters, except that 



RATIONAL SYMPTOMS. 127 

an expression of pain passes across it occasionally when the child 
coughs, or takes a deep breath. It is seldom deeply flushed as in 
pneumonia. The alse nasi are dilated only during the continuance 
of the difficulty of respiration. 

The decubitus is generally dorsal or indifferent. In the two 
cases observed by myself in which the effusion was large, the 
number of inspirations was always from three to five greater when 
the child laid on the sound, than when on the affected side. 

Headache is often present during the first few days, in children 
over six years of age. 

Convulsions are said to occur sometimes at the onset in very 
young children. The strength is not usually much diminished, 
except during the acute period. The appetite is generally dimi- 
nished and the thirst acute, but neither of these symptoms is 
so marked as in pneumonia. The tongue is usually moist, and 
sometimes covered with a coat of whitish fur ; the abdomen is 
natural. 

Bilious vomiting is said to occur in more than half the cases. 
The stools are generally regular, or there is some constipation. 

Auscultation practised soon after the invasion generally re- 
veals bronchial respiration without any rhonchus. The percus- 
sion is dull ; the cough, pain, fever, and difficulty of breathing 
continue for several days ; after which all but the cough generally 
disappear,' while that commonly persists. In acute cases, the 
appetite now begins to return, the thirst moderates, and ausculta- 
tion reveals only feebleness of the respiratory murmur and slight 
dulness on percussion. The general symptoms cease soon after 
this, and the patient is entirely convalescent in from one to three 
weeks, though feeble respiration and diminished sonoreity some- 
times persist for a longer period. 

Chronic pleurisy may follow the acute form, or occur as an 
idiopathic disease. In the former case, the acute symptoms 
diminish after a variable length of time, but the fever does not 
cease entirely and often recurs towards evening. In the latter 
case there is very slight fever or none at all, and the pain is 
vague, uncertain, and attracts but little notice. The effusion takes 
place gradually, and is generally large. The percussion is now 



128 PLEURISY. 

entirely dull over a greater or less extent of the side, and the re- 
spiratory sound is suppressed. The side is evidently enlarged, the 
increase of size being visible to the eye and ascertainable by 
measurement. If the case continues and terminates unfavourably, 
the child emaciates, grows pale, has night-sweats and heftic fever, 
and dies at last in a state of profound exhaustion. In favourable 
cases, on the contrary, the efFusion is gradually absorbed, and the 
patient recovers with a contraction of the side. In some rare in- 
stances the fluid has been evacuated by an opening through the 
parietes of the thorax, caused by ulceration or made by a sur- 
gical operation ; and in others again by an opening into the lung, 
through which the fluid has been expectorated. The recovery by 
absorption has been known to take place two and five months after 
the invasion. In one case that I saw, the duration from the time 
when the efFusion took place to its complete absorption was five 
weeks, and in the other between six and seven. 

Diagnosis. — Pleurisy may be confounded with pneumonia or 
hydrothorax. From the latter affection it is to be distinguished by 
the absence of pain in that disease, by the existence of the effusion 
on both sides of the thorax in most cases, and by the fact that hy- 
drothorax generally follows as a consequence of some previous dis- 
ease, particularly the eruptive fevers or nephritis. 

The distinction between acute or chronic pleurisy and lobular 
pneumonia is, as a general rule, very easy. Lobular pneumonia 
occurs almost always in children under six years of age ; it is ac- 
companied by a great variety and abundance of humid rhonchi on 
both sides, and by very slight dulness on percussion ; the vibra- 
tion of the parietes of the thorax continues : pleurisy, on the con- 
trary, occurs very rarely under six years of age, except as a se- 
condary affection ; it is unaccompanied by rhonchus of any kind ; 
the auscultatory signs are feeble respiration, bronchial respiration, 
and when the effusion is large, absence of all sound ; the vibration 
of the walls of the chest ceases to be perceptible ; and lastly, the 
percussion is much more dull than in lobular pneumonia, or it is 
flat. 

The distinction between acute pleurisy and lobar pneumonia is 
more difficult than either of the points which have just been con- 



DIAGNOSIS. 



129 



sidered, and in some instances is subject to considerable doubt. It 
may generally be arrived at, however, by attention to the diffe- 
rences laid down in the following table, which is taken from the 
Bibliotheque du Medecin Praticien. 



Acute Idiopathic Pleuris*. 

Frequent after six years of age; 
rare under that age. 

Begins with dry cough, sharp tho- 
racic pain, bronchial and metallic re- 
spiration during inspiration, either on 
the first day or later, and more rarely 
with obscurity of the respiratory sound. 

Modification of the physical signs 
by change of position. 

Fever and acceleration of the re- 
spiration usually moderate. Rapid 
diminution of these symptoms from 
the fourth to the seventh day. 

Expectoration absent or very slight. 

No rhonchi. 



Absence of vibration of the thoracic 
parietes during speaking or crying. 

Course of the disease irregular ; ra- 
pid disappearance in some cases, pro- 
longed duration in others. The bron- 
chial respiration is substituted or 
masked by feeble respiration. 



Acute Idiopathic Pneumonia. 

Frequent after six years of age ; 
more rare under that age, but much 
less so than pleurisy. 

Begins with cough, slight thoracic 
pain, and crepitant or sub-crepitant 
rhonchus ; at a later period there is 
bronchial respiration during the expi- 
ration and bronchophony. 

No modification under like circum- 
stances. 

Fever violent; considerable accele- 
ration of the respiration. Diminu- 
tion of these symptoms less marked, 
less rapid, and not before the sixth or 
ninth day. 

Expectoration mucous, sometimes 
sanguineous, very rarely rust-colonred. 

Rhonchi preceding, following, and 
often accompanying the bronchial re- 
spiration. 

Augmentation of vocal resonance 
very sensible in older children, and in 
a less degree in all. 

Course of the disease regular; stea- 
dily increasing, in most cases, and 
then diminishing from the sixth or 
ninth day. Bronchial respiration 
more disseminated. 



The chronic form of pleurisy with extensive effusion, may be 
easily distinguished by the history of the case, by inspection, pal- 
pation and mensuration of the chest, by the nearly total absence 
of sonoreity and of the respiratory murmur except at the inner 
edge of the scapula, and by attention to the character of the gene- 
ral symptoms. 



130 PLEURISY. 

Prognosis. — Acute pleurisy is rarely a fatal disease in healthy 
subjects. When it occurs as a complication of some other malady, 
on the contrary, it is much more apt to terminate unfavourably. 
The degree of fatality in secondary cases will depend, in great 
measure, on that of the primary disease. Pleuro-pneumonia is a 
more dangerous disorder than either alone. Of 5 cases of pri- 
mary pleuro-pneumonia, observed by Rilliet and Barthez, 2 died ; 
while of 10 secondary cases, 8 died. 

Chronic pleurisy is generally a serious, and not unfrequently, a 
fatal disease. Of 5 cases, observed by the authors just quoted, 2 
proved fatal. 

The three cases of pleurisy observed by myself, all of. which 
were acute in the beginning, though two became chronic after- 
wards, recovered. 

Treatment. — The hygienic treatment in this, as indeed in all 
the diseases of children, is of the utmost importance, and ought 
to be regulated by the practitioner himself. In all forms of the 
disease, the child should be carefully protected from cold, and in 
the acute form, kept at rest, and if possible, in bed. The diet 
must be very strict, and should consist for a few days of nothing 
but the weakest preparations of milk. After the fever has 
disappeared, bread and milk, vegetable soup with a few oysters 
boiled in it to make it agreeable, and gradually rice, potatoesVand 
at last small quantities of meat may be allowed. In the chronic 
form the diet ought to be less strict, but regulated with equal care, 
as to quantity and material. In that form the patient should be 
taken into the air if the weather be mild and dry, and in winter 
the chamber ought to be well aired from time to time. 

Bloodletting. — Depletion ought to be employed in acute pleu- 
risy, as a general rule. Blood may be drawn either by venesection, 
cups, or leeches, the quantity to be regulated by the age and con- 
stitution of the patient. Venesection is preferable to local deple- 
tion, unless there be some contra-indicating circumstance. From 
four to six ounces may be taken generally from a child between 
four and six years of age. It is seldom necessary to repeat the 
operation ; when, however, the acute symptoms are not at all re- 
lieved by the first detraction, it would be proper and useful to resort 



TREATMENT. 131 

again to a small venesection, to leeching, or to take two or three 
ounces of blood by cups, as recommended in the article on pneu- 
monia. 

Depletion ought to be avoided in most of the secondary cases 
unless the symptoms are very acute and the child strong and 
vigorous ; also in all chronic cases, after the febrile symptoms 
have been dissipated, and in feeble, delicate children, or, if resorted 
to, it should be used with very great circumspection. 

Antimonials. — A moderate use of the antimonials is of great 
service in the acute stage of the disease. Small doses of antimo- 
nial wine and sweet spirits of nitre, or fractional doses of tartar 
emetic, as recommended in the article on pneumonia, will gene- 
rally cause the fever, dyspnoea, and cough to subside rapidly. 
Large doses seem to be unnecessary in any case, and are liable to 
be injurious in many. 

Alteratives. — Many writers recommend the habitual employ- 
ment of the mercurial preparations in connexion with bloodletting. 
It seems to me, however, that they are, to say the least, seldom 
necessary in acute cases, since the majority of these are nearly 
certain to recover without a resort to them ; and it is better, as has 
already been said, to avoid the use of mercury in children when 
there are other and less powerful remedies which may be resorted 
to instead. When, however, acute pleurisy tends to assume the 
chronic form, and in confirmed chronic cases also, they would 
seem to be more clearly indicated, though under such circum- 
stances, I have succeeded in curing two cases, as I shall presently 
show, without a resort to them. Nevertheless, calomel combined 
with digitalis, has been recommended by very high authority under 
these circumstances. From a quarter to half a grain of that pre- 
paration, with a quarter of a grain of powdered digitalis, may be 
given every two or three hours. 

The remedy employed by myself, after the disappearance of 
the acute symptoms and when the effusion had taken place, was 
iodide of potassium in syrup of sarsaparilla, according to the fol- 
lowing formula : R. Potass, iodidi grs. xvi. ; Aqua?, Syrup. Sarsap. 
comp. aa gi. — M. Give a teaspoonful three times a day to chil- 
dren three or four years old. Under this treatment the effusion 



132 PLEURISY. 

disappeared rapidly, though diuretics had failed to make any im- 
pression on the cases. 

Diuretics are highly recommended in the treatment of cases in 
which effusion has taken place. Those chiefly employed are 
squills, digitalis, and nitre. The squill is given alone, or in com- 
bination with calomel or digitalis, or both. The dose of the powder 
of squill or digitalis is about a quarter of a grain every two or three 
hours. The squill may be used also in the form of syrup or oxy- 
mel, and the digitalis in tincture. These two substances were em- 
ployed by myself in the following formula : R. Acet. Scillee 3ii. ; 
Aquse fontis giv. — M. Give a teaspoonful with a drop of Tinct. 
Digit., three or four times a day to children two years old. This 
formula was made use of for several days in the two cases already 
referred to, without any perceptible diminution of the amount of 
the effusion, whereupon it was suspended, and the iodide of potas- 
sium as above recommended substituted, and with much better 
effect. 

Purgatives ought to be used during the acute stage of pleurisy 
to an extent sufficient to keep the bowels soluble, and to act as 
mild evacuants. In chronic cases, on the contrary, they are par- 
ticularly recommended as evacuants, in order to deple^ the blood- 
vessels, and thus hasten the absorption of the effusion. So far as 
my experience goes, this treatment is unnecessary, as diuretics and 
alteratives are generally sufficient, without a resort to violent re- 
medies which must irritate the intestinal mucous membrane, al- 
ways extremely susceptible in children, to a dangerous degree. 

External remedies. — Blisters are very generally employed in 
the acute form to relieve pain and dyspnoea, and in the chronic form 
to hasten the absorption of the effused liquid. I did not apply them 
in the cases under my charge, having succeeded very well without ; 
but would not hesitate to make use of a small one applied for a not 
longer period than two hours, if the pain and oppression continued 
after sufficient depletion and the use of antimonials. In chronic 
pleurisy, the application of a large Burgundy pitch plaster, made 
rather weaker than what is used for adults, and large enough to 
cover nearly the whole side, would, it seems to me, be preferable 
to blisters. 



TREATMENT CASE. 133 

Tonics are often necessary in chronic, and sometimes after the 
febrile symptoms have subsided in acute cases occurring in feeble 
and delicate children. The most suitable are quinine in the dose 
of a grain morning and evening, small quantities of very fine port 
wine, and the preparations of iron. 

Paracentesis. — When, in chronic pleurisy, the effusion is very 
large ; when there is no disposition to absorption, notwithstanding 
the use of proper remedies ; when the child is becoming very de- 
bilitated, and is attacked with hectic fever and night-sweats ; the 
operation of paracentesis has been recommended by very high 
authority, and has been performed with entire success on several 
occasions. M. Heyfelder [Arch, de Med., 3 serie, t. v., p. 59,) 
performed it in one case eight weeks, and in another four months 
and a half after the beginning of the attack. Both cases recovered ; 
the lung expanded again, the opening closed, and the respiration 
was nearly alike over both sides. 

Case of chronic pleurisy of the left side, beginning with acute 
symptoms ; extensive effusion with displacement of the heart to 
the right of the sternum; recovery. — February 12th, 1846. — The 
subject of the case is a boy four years old, of delicate stature 
and appearance, but enjoying good health. I saw him first at 1 
p. m. He was perfectly well yesterday, slept soundly last night, 
and rose apparently in good health this morning. He ate his 
usual breakfast, but complained afterwards of feeling unwell. 
Soon after this he complained of headache, of soreness and weak- 
ness of the knees in going up stairs, and then of violent pain in 
the left side beneath the armpit. 

At the time of my visit he was in bed, in the following condition : 
Pulse 130, full and strong.; skin warm and moist; headache; 
sharp, severe pain at the prsecordia, extending backwards under the 
armpit, and aggravated by motion, crying, and by deep inspira- 
tions ; respiration quick, and jerking. No cough at all, absolutely 
none. Abdomen natural ; neither vomiting nor diarrhoea. Tongue 
slightly furred, moist. Action of heart violent ; impulse strong, 
and felt over a large space ; sounds loud and strong, to the left 
and beneath the nipple, a soft murmur in second sound. Per- 
cussion dull over a larger space than natural. 

12 



134 PLEURISY. 

Behind, percussion dull over whole of left side ; natural on right 
side. Respiration natural on the right side ; feeble and indistinct, 
without bronchial sound on the left. 

Ordered a teaspoonful each of extract of senna and syrup of 
rhubarb, to be given immediately. To have a warm bath in the 
evening, and to take one of the following powders every two or 
three hours, beginning in the evening. R. — Pulv. Opii. et Ipecac, 
grs. iij. ; Potass. Nitrat. grs. vi. In pulv. No. vi. 

February 13. — Passed a restless night. Better to-day. Pulse 
130, softer; skin moist. Impulse of heart less violent. Pain not 
so severe. Respiration still quick, and when the child is ex- 
cited or irritated, it becomes jerking, while at other times it is 
quiet. Physical signs as before, except that the murmur in the 
second sound of the heart is no longer heard. Ordered three 
ounces of blood to be drawn by leeches from the left side ; pow- 
ders to be continued so as to allay restlessness and pain. 

February 14. — Has had a better night. Pulse less frequent. 
Respiration 30, and without jerking ; no cough at all ; makes no 
complaints of pain. The appetite is returning. 

February 15. — Better in all respects; no fever nor pain; no 
cough. Physical signs as before. 

The case went on until the 27th of March, when I paid my 
last visit, making the duration of the whole case over six weeks. 
During the last two weeks of February, there were no acute symp- 
toms. The fever had disappeared entirely. The respiration con- 
tinued, however, from 28 to 30 during all that time. The effu- 
sion occupied nearly the whole of the left side, which was mani- 
festly larger than the right, and the intercostal spaces were en- 
larged. Behind, there was total flatness on percussion from the 
spine of the scapula downwards, and in front from a short distance 
below the clavicle. The respiratory murmur was absent in the 
lower three-fourths of the dorsal region, and feeble above. In 
front, respiration was heard only above and just beneath the clavi- 
cle. In the course of this period, the heart was gradually forced 
over to the right side of the sternum, so that at last its impulse 
was felt, not to the left, but to the right of the sternum. The car- 
diac sounds wore loudest and most distinct in the same region. 



CASE. 135 

The displacement was so remarkable that the mother discovered 
it herself, I having avoided telling her, to save her from anxiety. 
The new position of the heart did not seem to produce any incon- 
venience, in addition to that occasioned by the pleuritic effusion. 
During the last two weeks of March, the child was kept in bed ; 
his diet was milk and bread ; a large Burgundy pitch plaster was 
kept on the side, and he took internally vinegar of squill, and 
tincture of digitalis. 

Finding that the effusion remained stationary under this treat- 
ment, I prescribed a grain of iodide of potassium to be given three 
times a day, in a teaspoonful of compound syrup of sarsaparilla. 
The diet was changed at the same time. He was allowed small 
quantities of meat every day, and was taken from bed and placed 
in a chair by the window. Under this treatment, he gradually 
improved, so that by the 27th of March, when I paid my last 
visit, the effusion had in great measure disappeared, and he was 
able to play about the room all day. The side was slightly con- 
tracted ; the respiration was pure and vesicular, but rather more 
feeble than on the left side ; the heart had returned to its natural 
position. 

I have examined this child in the course of the present year 
(1847), and find him to be in as good health as before his sick- 
ness. Excepting a slight contraction of the left side, there is no 
perceptible difference between that and the right. 

ARTICLE IV. 

HOOPING-COUGH, OR PERTUSSIS. 

Definition ; synonymes ; frequency. — Hooping-cough is cha- 
racterized by a hard, convulsive cough, occurring during expira- 
tion, and accompanied by long, shrill, and laborious inspirations, 
which are called hoops. The cough occurs in paroxysms, which 
are terminated by the expectoration of tough phlegm and often by 
vomiting. 

The disease is known by various other names, of which the 



136 PERTUSSIS. 

most common are tussis ferina, chincough, and kincough. The 
frequency of the disease is exceedingly variable, as it occurs both 
in the sporadic form and as a widely prevailing epidemic. Some 
idea of its frequency may be gained from the facts that during 
the ten years preceding 1845, there were 781 deaths from it in 
Philadelphia, under fifteen years of age. During the same time 
there were 1592 deaths from pneumonia; 1149 from croup; and 
1172 from bronchitis. (Condie, Dis. of Child., 2d edit, note, p. 88.) 

Causes. — Age. — It occurs generally in young children. Of 130 
cases in children, collected by M. Blache, 106 were between 1 and 
7 years of age, and only 24 between 8 and 14. Of 29 cases 
observed by Rilliet and Barthez, there were 26 between 1 and 7 
years, and 3 between 8 and 12. Of 49 observed by myself, 
there were 9 under 1, 37 between 1 and 7, and 3 between 8 and 
10 years. It is stated by MM. Blache, Rilliet and Barthez, and 
Valleix, to be most common in girls. Of the 49 cases observed 
by myself, 27 occurred in boys, and 22 in girls. Some writers 
have asserted that certain constitutions and hereditary influence 
predispose to the disease. So far as my own experience goes, it 
has seemed to attack indifferently those who were simultaneously 
exposed to it. The fact of its being propagated by direct conta- 
gion is proved beyond doubt by numerous observations. I have 
rarely known one child in a family to be attacked without 
its extending to all the others not protected by having had the 
disease previously. That it often appears also in the form of an 
epidemic, is established by the testimony of many writers, so that 
at present no doubt is entertained upon this point. 

Symptoms. — It is customary to describe three stages of hooping- 
cough. The first is called the stage of invasion, or the catarrhal 
stage ; the second the stage of increase, or the spasmodic stage ; 
and the third the stage of decline, which is characterized by an 
amendment of all the symptoms. 

First stage. — The great majority of the cases begin with the or- 
dinary symptoms of simple catarrh. These are coryza, sneezing, 
slight injection of the conjunctivae, and dry cough. The cough 
rarely has any peculiarity in the beginning which will enable us 



SYMPTOMS. 137 

to distinguish it from that of an ordinary cold, though some per- 
sons have asserted that they could recognise it. I have often 
listened with great care to the sound of coughs which parents sup- 
posed might be hooping-cough, but was always obliged to confess 
my inability to determine, until time gave them more decided 
characters. In addition to the symptoms enumerated, there is 
generally more languor, lassitude, drowsiness, and irritability, 
than are commonly present in simple catarrh. In a small propor- 
tion of cases the first stage is wanting, and the disease assumes 
its peculiar features from the first. The duration of this stage is 
very uncertain, and is ascertained with difficulty. My own ex- 
perience would fix it at about two weeks as the average, though it 
may last undoubtedly a much shorter, or longer period. 

Second stage. — At the beginning of this stage the disease has 
assumed its peculiar convulsive and paroxysmal characters. It 
consists of violent fits or paroxysms, or as they are often 
called, kinks of cough, recurring after longer or shorter intervals. 
Just before the paroxysm the child seems restless, anxious, and 
irritable, or else keeps perfectly quiet and evidently tries to retard 
its approach. When it begins, the child, if lying down, rises up 
suddenly, or if playing about runs to take hold of some fixed ob- 
ject, by which to support itself during the accession. The cough 
is dry, spasmodic, and sonorous, and occurs in a succession of 
short, rapid expirations, by which the thorax seems to be emptied 
of all its air, with violent efforts. It is followed by one or two 
long and deep inspirations, which are accompanied by the peculiar 
hoop to which the disease owes its name, in consequence of the 
drawing of the air through the narrowed glottis, which is spas- 
modically closed. During the fit the face becomes deeply suffused 
or even purple, and swollen ; the eyes are watery, and the coun- 
tenance expressive of great anxiety, and after the fit is over, of 
fatigue and exhaustion. The latter symptoms are, as M. Valleix 
remarks, the signs of partial asphyxia, and are the result doubtless 
of the complete expulsion of air from the thorax, and consequent 
momentary suspension of the function of hsematosis. There is 
almost always an expectoration of colourless ropy fluid, often 
accompanied by vomiting, at the close of the fit of coughing, and 

12* 



138 PERTUSSIS. 

the patients usually appear weak and languid for a short time, 
after which they return to their play. 

In very severe cases there are other symptoms in addition to 
those just mentioned. Hemorrhages from the mouth, ears, nose, 
lungs, and beneath the conjunctiva, are not unusual. I have seen 
several instances of epistaxis, and one of extensive sub-conjunctival 
ecchymosis myself, and I am well acquainted with the history of 
another, in which there was bleeding both from the nose and ears. 
In another, in a girl two years of age, which came under my own 
observation, a species of syncope, a state of insensibility without 
convulsive movements, accompanied by great paleness, occurred 
after many of the paroxysms. I have met with general convul- 
sions in four cases, two of which were fatal. In two other cases, 
both occurring in infants under six months, the paroxysms of 
cough were accompanied by the most violent struggling and op- 
pression, and by deep blueness of the hands and feet, like that of 
severe cyanosis. 

In some instances, after the paroxysm is apparently over, the 
child will begin within a few instants to cough again, and may in 
this way have several fits in such rapid succession as to make an 
almost continuous paroxysm. It is quite common for this to 
happen twice, and in one case which I saw, it occurred three 
times on several occasions. The ordinary duration of a paroxysm 
or kink, is from a quarter to three quarters of a minute, though it 
may last as long as two minutes, or according to some even 
longer. The number of accessions in twenty-four hours is very 
irregular. It depends chiefly on the stage and violence of the 
attack. During the height of the disease, I have generally found 
them to number about 40. In some rare cases, however, they are 
much more numerous, and amount to 70 or 80. They are gene- 
rally most frequent in the course of the third or fourth week, after 
which they remain stationary for two or three weeks, and decline 
gradually. The paroxysms may occur spontaneously, the child 
being often disturbed from sleep by their sudden occurrence, or 
they may be excited by various circumstances, such for instance 
as contrarieties, a fit of crying, change of position, eating, violent 
exercise, and imitation. I have frequently seen an attack brought on 



SYMPTOMS. 139 

by the sight of another child in a paroxysm of the disease. The 
duration of the second stage is stated by Rilliet and Barthez to be 
about 30 or 40 days in most cases. 

Third stage. — It is impossible to fix a precise limit from which 
to date the beginning of this stage. It is generally, however, said 
to commence from the time when the disease is evidently on the 
decline. The paroxysms now grow less frequent and less vio- 
lent, the cough reassumes some of the catarrhal features which it 
had at first, and gradually loses its peculiar spasmodic character. 
The child's general health improves ; the appetite becomes vigor- 
ous, the strength is invigorated, the sleep again becomes sound 
and tranquil, and the disease disappears. The duration of this 
stage is uncertain like that of the two others. Rilliet and Barthez 
state it to be short in uncomplicated cases (ten to fifteen days), and 
are of opinion that when it has been supposed to have lasted several 
weeks or months, it has been the result of some complication, as 
chronic dilatation of the bronchia, tubercular disease, etc. It hap- 
pens not unfrequently, however, that after the disease has appa- 
rently ceased, all the distinctive characters of the cough recur, if 
the child chances to take cold within a few weeks or even longer 
after its disappearance. 

In cases of pertussis unaccompanied by complications of any 
kind, there are no marked general symptoms. There is seldom 
any fever, the appetite continues good, and with the exception of 
occasional languor and fatigue, and irritability of temper, the child 
appears to be well. 

The total duration of the disease, in simple cases, may be 
stated at from one to three months, according to Rilliet and Bar- 
thez. 1 have never known a case to last so short a time as a 
month, and have rarely found the whole duration much within 
three months. 

Complications. — Though it has happened to me on several oc- 
casions, to meet with children who have been very ill from the 
violence of the disease under consideration, in its uncomplicated 
condition, I have never known a case to prove fatal, except 
in consequence of some kind of complication. It seems to me 
very important, therefore, that the various complications liable 



140 PERTUSSIS. 

to occur in the course of the disease, should be carefully con- 
sidered. 

Convulsions. — This complication is not a rare one, since it oc- 
curred in 5 of 29 cases observed by Rilliet and Barthez, and in 
3 of 49 observed by myself. It is one of the most dangerous 
accidents liable to occur in the course of the disease. Of the 7 
cases reported by the authors quoted, (5 of their own, and 2 be- 
longing to M. Papavoine,) 6 died. Of my 3 cases, 2 died. In 
all that I have seen, the convulsions were general, extremely 
violent, and accompanied by insensibility in the fatal cases to 
the last, and in the favourable one, for several hours. In the two 
fatal cases the pertussis had lasted nearly two months, and was 
accompanied by extensive lobular pneumonia. The fatal event 
took place within twenty-four hours from the supervention of the 
spasms. The subjects were eight and nine months of age respec- 
tively. 

The favourable case occurred in a child five months old, who 
had been attacked with lobular pneumonia three days before the 
occurrence of the convulsions, which came on during the height of 
a severe paroxysm of coughing. The convulsive movements were 
general and continued for about half an hour, after which the 
child was drowsy or irritable for some hours longer. The hoop- 
ing-cough continued to be severe for two weeks after this, as many 
as 42, 46, and 48 paroxysms occurring every day. At last, how- 
ever, perfect recovery took place. It is proper to call the attention 
of the reader to the fact, that the 3 cases observed by myself 
occurred under one year of age. 

Bronchitis is a very frequent, complication. The authors above 
quoted found it to exist either alone, or combined with pneumonia, 
in half of the fatal cases. Of the 49 cases observed by myself, it 
existed to a greater or less extent, in its simple form, in 16. All 
of these recovered, so. that it cannot be regarded as a very dan- 
gerous accident. In fatal cases it has often been found accompa- 
nied by continuous dilatation of the smaller bronchia. 

Pneumonia, according to the authors above quoted, is about as 
frequent as bronchitis. When, however, the fatal termination took 
place soon after the beginning of the disease (18th, 26th, or 27th 



COMPLICATIONS — DIAGNOSIS. 141 

days), it was not generally present. After these periods, on the 
contrary, it was almost always observed. 1 have met with well- 
marked pneumonia only in 5 of the 49 cases referred to, and in 
1 other, making 6 in all. Of these, 4 were lobular and 2 lobar. 
Of the 4 children affected with lobular pneumonia, 3 were under 
one year, and the fourth between one and two years of age. Two 
of these died in convulsions, and one in a state of marasmus. The 
cases of the lobar form of the disease occurred in girls of seven 
and nine years of age respectively, and both recovered. This 
complication is much more dangerous therefore than simple bron- 
chitis ; the degree of danger is in proportion to the earliness of the 
age at which the disease occurs, and to the extent of the inflam- 
mation. 

Emphysema has been supposed by some to be a common result 
or accompaniment of the disease. This is denied, however, by 
others. I have never observed it myself, and as nearly all the 
children whom I have attended with pertussis continue to be under 
my observation, I should certainly have noticed it, were it of com- 
mon occurrence. 

Vomiting is a very frequent incident in pertussis, but ought not 
to be regarded as a complication unless dependent on some dis- 
ease of the digestive organs, or symptomatic of cerebral disease. 
Where it occurs in simple cases, or in those complicated with 
bronchitis or pneumonia, it has always seemed to me to be advan- 
tageous. 

Tuberculization is not infrequent, according to the French au- 
thorities, as a sequence of the disease. In the majority of the 
cases the tubercular deposit is concentrated in the lungs and 
bronchial ganglions. I am disposed to believe that it is of rare 
occurrence in this city, at least amongst the better classes, as I 
very seldom meet with it, or indeed with any form of tubercular 
disease in children. 

Diagnosis ; prognosis. — The diagnosis of pertussis is difficult 
only during the first stage of the complaint. It seems to me, in- 
deed, impossible to distinguish, during that stage, between it and 
simple mild laryngitis, or the mild catarrhal attacks which are so 
common in our climate. After it has once fairly entered upon the 



142 



PERTUSSIS. 



second stage, it is scarcely possible to confound it with any other 
malady. Rilliet and Barthez state, however, that acute bronchitis 
with paroxysmal cough is not unfrequently mistaken for pertussis. 
The mistake will scarcely be made, if it be recollected that in 
acute bronchitis with paroxysmal cough, the invasion is sudden ; 
that there is violent fever, great dyspncEa, and the physical 
signs of bronchitis ; that the hoop is generally wanting, or feebly 
marked* and that the disease is violent and rapid in its course ; all 
of which circumstances are widely different from what occurs in 
pertussis. 

The same authors assert that tuberculosis of the bronchial 
ganglions gives rise to a cough which may be mistaken for per- 
tussis. The following table extracted from their work will show 
the differences between the two disorders. 



Pertussis. 

Often epidemic, attacking several 
children at once; transmissible by 
contagion. 

Three distinct stages, of which only 
the second accompanied by kinks. 

Kinks attended with hooping, ropy 
expectoration, and vomiting. 

Pure respiration in the intervals be- 
tween the kinks. 

In the intervals between the kinks 
respiration and pulse natural, so long 
as the disease is simple. 



Voice natural. 

Course generally acute. 



Tuberculosis of the Bronchial 
Ganglions. 

Always sporadic; non-contagious. 



No distinct stages. 

Kinks generally very short, with- 
out hooping, ropy expectoration, or 
vomiting. 

Physical signs of tuberculosis of 
the ganglions; but in certain cases, 
absence of these signs. 

.Accessions of asthma in some cases, 
with the kinks ; continuous febrile 
movement, with evening exacerba- 
tions ; sweats ; progressive emacia- 
tion, &c. 

Voice sometimes hoarse. 

Chronic course. 



Prognosis. — Pertussis is rarely a dangerous or fatal disease so 
long as it remains simple. Of the 49 cases observed by myself, 
27 were simple, all of which recovered. Nevertheless, even the 



PROGNOSIS NATURE. 143 

simple disease does sometimes terminate fatally, from the exces- 
sive violence of the paroxysms of coughing. 

The danger in hooping-cough, which is considerable, depends, 
therefore, almost entirely on the complications which are so apt to 
occur, for which reason the physician should watch with the 
closest attention, in order to prevent their occurrence, and that he 
may recognise and treat them in their earliest stages. The most 
dangerous complication is convulsions, and after that bronchitis 
and pneumonia. So long as the child seems well and lively, and 
without fever or dyspnoea in the intervals between the fits, there is 
nothing to be feared. But if, on the contrary, it becomes languid 
and irritable, with indisposition to take food, feverishness, and 
some increase of the rate of respiration, the practitioner should be 
upon his guard. A very early age and natural delicacy of con- 
stitution are unfavourable circumstances in the disease. I have 
already stated that complications occurred in 22 of the 49 cases 
observed by myself. Of these, 3 died, one at the age of eight, one 
at that of nine months, and the other at that of a year and a half. 
Nature of the disease. — There is no essential anatomical lesion 
in pertussis, except, perhaps, slight inflammation of the bronchial 
mucous membrane. In most of the cases, the membrane lining 
the larger and smaller air-tubes, and very rarely that of the tra- 
chea, is reddened and perceptibly thicker than natural, and the 
tubes contain a considerable quantity of frothy mucus, or a thick, 
viscid, and tenacious phlegm. 

As to the nature of the disease, it seems to me very clear that 
it ought to be regarded as containing two elements of morbid 
action, one of which consists in slight inflammation of the respi- 
ratory mucous membrane, and the other of disordered action of 
the respiratory system of excito-motory nerves. It is neither a 
pure neurosis nor a pure inflammation, but partakes of the cha- 
racters of both, and much more of the former than of the latter. 
The authors of the Compendium de Medecine Pratique (t. ii., p. 
526) regard it as a neurosis on the following grounds : 1. "In the 
greater number of cases, the respiratory apparatus presents no 
kind of alteration, or else the lesions are so multiplied or variable 
that they are surely not the real origin of the disease ; 2. The 



144 PERTUSSIS. 

clearly remittent course of the symptoms and the total absence of 
fever, unless some complication is present, are not observed in 
ordinary or even specific inflammations ; 3. The cessation or 
sudden return of the paroxysms under the influence of moral 
emotions or change of place, belong to a disorder of innervation 
and not an inflammation, which commonly passes through cer- 
tain stages before it is resolved ; 4. The complete return to 
health, the integrity of all the functions in slight cases, the resis- 
tance which it opposes to treatment, the uselessness of antiphlo- 
gistica, and the success obtained from narcotics and antispasmo- 
dics, are all so many circumstances peculiar to hooping-cough 
and to many of the neuroses." 

Treatment of simple pertussis. — Bloodletting. — Depletion is very 
rarely necessary in simple pertussis. The only cases in which it 
can be called for are those occurring in sanguine children, where 
the paroxysms are so violent as to endanger the brain by over-dis- 
tension of the vessels. In these cases a small bleeding, or the ap- 
plication of a few leeches to the temples or behind the ears, may 
be proper ; but even these may often be safely treated by reduced 
diet and by a few doses of saline cathartics, without a resort to the 
more powerful and more permanently exhausting means of deple- 
tion. As for the treatment of simple pertussis by repeated vene- 
sections, in the hope of curtailing its duration, or under the idea of 
their being rendered necessary by the violence of the malady, it 
seems to me forbidden by the present state of medical knowledge, 
which informs us that pertussis, like the exanthemata, has a 
certain course through which it must pass, and that the greater 
number of the cases do not endanger life so long as they remain 
simple, however violent they appear to be. Of the 27 simple 
cases treated by myself, depletion was not used in any, and all re- 
covered. 

Antispasmodics. — Of the different remedies of this class which 
have been used in the disease, I shall only mention assafoetida, 
which is recommended upon very high authority, and is doubtless 
useful in moderating the severity of the paroxysm. It is much 
employed in this city as a domestic remedy. I have used it my- 
self on several occasions with some benefit ; but, as I have ob- 



TREATMENT. 145 

tained better and more constant success from other means, T now 
seldom resort to it. Dewees speaks of it as " occasionally useful, 
but never decidedly efficacious" in his hands. Kopp recommends 
it very strongly, in the dose of six grains three times a day in pills, 
for a child four years old. This seems to me a large dose. I 
have generally given two or three grains three or four times a day 
to a child of that age. 

Narcotics. — Of the various narcotics which have been more or 
less extensively employed, the most important are belladonna, 
opium, and hydrocyanic acid. Belladonna is highly recom- 
mended by several German authors, by Rilliet and Barthez, who 
state that it is beyond contradiction the one most deserving of 
confidence, by Trousseau and Pidoux, and by Dr. Eberle. It 
ought to be given with great care, and not continued for too long 
a time. Eberle says that it ought not to be exhibited where there 
is fever and bronchial inflammation. Trousseau and Pidoux employ 
the following formula : R. — Pulv. Belladonnas gr. iv ; Extract. 
Opii aquos. gr. iv ; Extract. Valerianae 3ss. Ft. in pilul. no. xvi. 
Give from one to four in the course of the day. If the child dis- 
like the pilular form, they give it in syrup, according to the fol- 
lowing formula : R. — Extract. Belladonnas gr. iv ; Syrup. Opii, 
Syrup. Flor. Aurantii, aa gj, Misce. Of this, from one to eight 
teaspoonfuls are to be given in twenty-four hours. I have seldom 
made use of belladonna, and can, therefore, give no personal opi- 
nion as to its efficacy. 

Opium is confessedly a very valuable remedy in the disease, not 
as a curative, but as a sedative and palliative. When the cough 
is frequent and fatiguing, especially if the patient have an irri- 
table and nervous constitution, some opiate preparation is of the 
utmost service in moderating the frequency and violence of the 
paroxysms, and in allaying irritability and restlessness. It is best 
given in the evening, and in combination with ipecacuanha, or 
very minute doses of antimony. 

Hydrocyanic acid has been employed by various observers, 
and is highly spoken of by some. Its poisonous properties, how- 
ever, have deterred many, and amongst them, myself, from re- 
sorting to it. Inasmuch as there are other and safer means for 

13 



1 46 PERTUSSIS. 

conducting the disease to a favourable termination, it seems to me 
useless to venture upon so potent a preparation as this. Dr. Atlee, 
of Lancaster, gave it in the following formula : R. — Acidi Hy- 
drocyanic ffX) ; Syrup. Simpl. 3j. — M. A teaspoonful given 
morning and evening ; and if no uneasiness, dizziness, or sickness 
be produced within forty -eight hours, the dose to be repeated, three 
times a day. This prescription is for a child six years old ; one 
drop of the acid being added for each year of the child's age 
beyond one year. He has never repeated the dose more than four 
times a day. {Condie's JDis. of Child. 2d ed. p. 337.) 

Emetics and Nauseants are amongst the most important reme- 
dies in the treatment of hooping-cough, since they exert a powerful 
influence upon the disease, and unless carried to excess, are not in 
themselves likely to be injurious. Some authors recommend the 
administration of an emetic every day or every other day, while 
others give them according to the necessity of the case. Believing 
that frequently repeated emetic doses are unnecessarily severe, and 
productive of too much fatigue and exhaustion, I have preferred 
in the simple disease, to give only small doses of ipecacuanha 
from time to time, so as to moderate the violence of the cough. 
Tartar emetic is seldom necessary, and ought to be avoided if pos- 
sible, on account of its disposition to irritate and inflame the 
gastro-intestinal mucous membrane. The syrup of ipecacuanha 
is the preparation I have almost always used. From ten to twenty 
drops, given three times a day to a child three years old, will 
very generally moderate the severity of the paroxysms. 

Purgatives are necessary in the simple disease only when con 
stipation is present. The mildest ought to be preferred, in order 
to avoid irritation and exhaustion. Castor oil, magnesia, or syrup 
of rhubarb are the best. 

Particular remedies.— -Of the different specific remedies that 
have been employed, none have attained and maintained so high 
a reputation in this city as the carbonate of potassa, which, in the 
form of the cochineal mixture, is constantly used both by physi- 
cians and as a domestic remedy. The following formula is the 
one generally administered : R. — Potass. Carbonat. 9j ; Cocci 
9ss ; Sacch. alb. 3j ; Aquce fontis, 3iv.— M. Give a dessert spoon- 



TREATMENT. 147 

fill three times a day to a child a year old. Believing the carbo- 
nate of potash to be the active agent in the mixture, I have gene- 
rally left out the cochineal and used the potash alone, dissolving 
it in equal parts of syrup of gum and water. I have frequently 
employed this remedy and believe that, with the exception of 
alum, to which I shall presently refer, it is the most useful agent 
in keeping down the violence of the disease with which I am ac- 
quainted. I have given it in the dose of a grain three and four 
times in the twenty-four hours, to children one and two years old, 
for several weeks at a time, without witnessing any injurious 
effects from it. 

Alum is highly recommended as a remedy in pertussis by Dr. 
Golding Bird (Guy's Hospital Reports, April 1845). He states 
that in the second or nervous period of the disease, when " all 
inflammatory symptoms have subsided, and when, with a cool 
skin and clean tongue, the little patient is harassed by a copious 
secretion from the bronchi, the attempt to get rid of which pro- 
duces the exhausting and characteristic cough, alum will be found 
to be of much value." He adds that he " has not yet met with 
any other remedy which has acted so satisfactorily, or afforded 
such marked and rapid relief." From reading Dr. Bird's remarks 
on alum, and prompted by my knowledge of its admirable quali- 
ties in the treatment of croup, I was led to make trial of it in the 
disease under consideration, and I believe I may say that it has 
exerted a more decided influence in moderating the violence of the 
disorder, than any that I have ever made use of. I have admi- 
nistered it in 15 cases, beginning in the course of the second 
stage. In all it was beneficial, and in some the effects were strik- 
ingly useful, the improvement being more rapid than I had ever 
seen to result from other remedies, or to occur when the disease 
has been allowed to pursue its natural course. In a boy between 
five and six years of age, who had been coughing violently for 
two weeks, the paroxysms diminished so much in intensity and 
frequency after he had taken the remedy two days, that he was 
not once disturbed at night, though before he had always been 
waked several times, and the spells which occurred during the 
day were much less severe. After continuing the remedy for 



148 PERTUSSIS. 

ten days, the disease had subsided so much that its employment 
was suspended. Soon after, however, the paroxysms again be- 
came severe and troublesome. The alum was resumed, and with 
the same results as at first. In another family in which there 
were three children, all of whom had been taking syrup of ipe- 
cacuanha, and carbonate of potash for some days, without any 
good effects, the alum was given, and acted as in the case first 
referred to. The nights were comparatively quiet, and the spells 
occurring through the day, very much moderated. I may repeat 
that, so far as my experience in the above 15 cases goes, the 
effects of alum have been more decided and satisfactory than 
those of any other remedy. I have never known it to produce 
bad consequences either at the time of its administration or subse- 
quently, though I have given it to children from two months to 
seven years of age, and have continued its use from one to five 
weeks at a time. If administered in large doses it produces vo- 
miting. It does not constipate, but on the contrary, is apt to in- 
duce diarrhoea, when continued for some time. Dr. Bird gives 
from two to six grains every four hours. His formula is as fol- 
lows : R. Aluminis, gr. xxv ; Ext. Conii, gr. xii ; Syrup. Rhoea- 
dos, 3ii ; Aquse Anethi, giii. — M. Give a medium-sized spoonful 
every six hours. I have not generally used it in such large doses. 
To children under one year I give from half a grain to a grain, 
three or four times a day ; and to those over that age, two grains 
every six hours. The formula I have employed is the follow- 
ing: R. Aluminis, 9iiss ; Syrup. Zingib., Syrup. Acacise, Aquse 
fontis, aa gi. — M. When this is prepared with good syrups, it 
tastes very much like lemonade, and is not at all unpleasant, so 
that children take it without difficulty. The dose is a teaspoonful 
three times a day, or every six hours. 

Sulphur. — Some of the German authorities make frequent use 
of, and greatly commend the effects of flowers of sulphur, both at 
the beginning and throughout the course of the disease. Rilliet 
and Barthez state that they saw it succeed several times in the 
hands of M. Jadelot. I have never employed it. It is given in 
doses of three grains two or three times a day, to children from 
two to four years of age ; and to those who are older, in doses of 



TREATMENT. 149 

fifteen grains or more in twenty-four hours. It may be admi- 
nistered in powder diffused in milk or syrup, or made into an 
emulsion. It is said not to be purgative in the doses mentioned. 

Various other remedies have been recommended by different 
authors, the most important of which are the subcarbonate of iron 
used by Dr. Steyman, and by Lombard of Geneva ; the misletoe, 
(Viscum Album), employed by Baglivi and J. Frank, and recently 
by Guersent and Blache, who give it in powder, in the dose of 
twelve or fourteen grains four times a day ; and the cicuta, which is 
highly spoken of by several German authors. 

Revulsives. — The milder revulsives are useful in certain com- 
plications of pertussis, and as palliatives. To make them the chief 
basis of the treatment, however, which has been done by some, 
appears to me to be wrong. In order to produce a decided im- 
pression upon the disease, it would be necessary to resort to the 
more powerful remedies of the class, such as moxas, issues, tartar 
emetic ointment, blisters, etc., the use of which is not, I believe, 
warranted by the nature of the disorder. 

Treatment of the complications. — If any of the diseases which 
have been mentioned as apt to occur during pertussis should arise, 
the treatment which is proper for them in their idiopathic form, 
must be adopted without regard to the hooping-cough, with the 
following rese vations : that care must be taken not to use means 
of too powerful and exhausting a nature, or such as have a tendency 
to irritate the organs with which they come in contact. For, it 
must be recollected, that after the complication is cured, the patient 
still has the original disease to go through with, and therefore re- 
quires all his strength ; and, moreover, the various organs of the 
body are predisposed by the very fact of the existence of the ori- 
ginal malady, to assume diseased action, should any irritation in 
the shape of a violent remedy be applied to them. 

The cases of bronchitis which came under my observation were 
treated in the simplest manner. The children were put to bed, 
their diet carefully regulated, the bowels gently opened with castor 
oil or syrup of rhubarb, and small doses of syrup of ipecacuanha 
or antimonial wine, with sweet spirits of nitre, administered every 
two hours. Mustard poultices were applied once or twice a day 

13* 



150 PERTUSSIS. 

to the inter-scapular space, and mustard pediluvia used every night, 
or more frequently if the dyspnoea were considerable. If the 
bronchial secretions were very profuse, and the cough trouble- 
some, the decoction or syrup of seneka was given in connexion 
with occasional doses of laudanum or paregoric. 

The complication of pneumonia was treated somewhat differ- 
ently. In the two cases of the lobar form, in children seven and 
nine years old respectively, one, the eldest, was bled from the arm, 
and the other leeched. The rest of the treatment consisted in the 
administration of small doses of antimonial wine and nitre, in the 
manner pointed out in the article on pneumonia, in the use of 
small doses of Dover's powder, and of the foot-bath. Both re- 
covered. 

The four remaining cases of pneumonia were of the lobular form, 
of which three proved fatal. The subjects of the fatal cases were 
eight months, nine months, and eighteen months of age respec- 
tively. They were treated principally with ipecacuanha, occa- 
sional laxatives, small doses of anodynes, and with mustard poul- 
tices and pediluvia. In one a blister was applied between the 
shoulders, but with most unfortunate results ; since the vesicated 
surface sloughed, and added very much to the sufferings of the 
child. The fourth case occurred in a boy five months of age. In 
this a violent attack of convulsions occurred on the third day of the 
pneumonia. The child was immediately placed in a warm bath, 
and large sinapisms applied over the front of the chest and upon 
the extremities, after which he was treated with half grain doses 
of alum, repeated every three or four hours, mustard pediluvia and 
poultices, and small doses of wine of opium. On the sixth day the 
pneumonia was resolved with copious sweats and cold hands and 
feet, for which small quantities of brandy and water and wine 
whey were used. The recovery was perfect. 

When convulsions occur they must be treated according to the 
cause which produces them, and the constitution and present state 
of the child. If the patient be strong and sanguine, and not ex- 
hausted by previous sickness, the treatment should consist of de- 
pletion by venesection, or by leeches to the temples, or behind the 
ears ; of cold applications to the head ; the warm bath ; cathartics 



TREATMENT. 151 

or purgative enemata ; and revulsives in the form of sinapisms, or 
of a small blister to the nucha. If, on the contrary, the patient is 
of delicate constitution, or exhausted by long illness, we must be 
content to resort to warm baths, revulsives, antispasmodics and 
anodynes, and stimulating enemata. 

Of the 4 cases of convulsions which came under my notice, 
the 3 already referred to, and one other, two proved fatal. Both 
of these occurred in children who had long been labouring under 
lobular pneumonia, that had baffled all treatment. Death took 
place within twenty- four hours from the appearance of the convul- 
sions, which were in fact the result of the diseased condition of the 
lungs. No treatment further than the warm bath and sinapisms, 
was resorted to. Of the two favourable cases, one has just been 
described under the head of pneumonia. The other occurred in a 
hearty boy nine months old, and seemed to depend on congestion of 
the brain, brought on by a severe fit of coughing. In this instance 
a venesection to a small amount was performed, the child was 
placed in a warm bath and cold applied to the head. No return of 
the spasms took place and the child recovered without difficulty. 

Hygienic Treatment. — This part of the management of the 
disease is of the highest importance, for it is by careful attention to 
its details, that the complications which constitute the chief danger 
of the malady, are to be prevented. In a considerable number of 
cases of pertussis, nothing more need be done than to insist upon 
strict attention to hygienic rules. The chief indications are to 
preserve the child from taking cold, and to prevent indiscretions in 
diet. The clothing ought to be warm, and during the autumn, 
winter, and spring, flannel should always be placed next to the 
skin. The child ought to be kept in the house during damp 
weather at all seasons, and in the winter season, whenever it is 
intensely cold. The diet should be nutritious, but of easy digestion. 
All heavy, rich food ought to be absolutely forbidden during the 
continuance of the malady. 

Treatment of the Paroxysm. — It often happens that the parox- 
ysms are so violent, that the child seems to be in imminent danger 
of suffocation or convulsions. This is especially true of infants. 
In three cases which I have seen, in infants of two, three, and five 



152 PERTUSSIS. 

months old, the kinks lasted so long, and the spasm of the larynx 
was so unyielding, that the children struggled as though labouring 
under tetanus ; the countenance was disturbed and anxious ; the 
face and hands, at first flushed, became purple from deep conges- 
tion ; and on some occasions the breathing was suspended for 
several seconds, so that life seemed for the time in the greatest 
danger. The difficulty in these cases depends on the spasmodic 
closure of the glottis, which is, sometimes, no doubt, completely 
shut. I have never known these alarming symptoms of asphyxia 
to occur when the hoop has been clear and distinct, for when that 
is present, the larynx is much less tightly closed. 

When the symptoms above described occur in older children, 
they should be raised and supported in the sitting posture ; when 
in infants, they ought to be held lightly in the arms, so that they 
may take any position which instinct prompts them to. At the 
same time cold water ought to be sprinkled from the fingers upon 
the face ; the child should be gently fanned, or, if the weather 
be warm, taken to the open window ; if there be time, it is well 
to put the feet into mustard water. It has been recommended on 
such occasions to apply compresses dipped into cold water to the 
sternum. I would propose the trial of a means w T hich my father 
found very successful in arresting tonic spasm of the respiratory 
muscles, in a case of laryngismus stridulus. This is the sudden 
application of a piece of ice wrapped in linen to the epigastrium. 
When the laryngeal spasm is very intense and obstinate, a small 
blister to the front of the neck, is useful in controlling it. 



CLASS II. 

DISEASES OF THE DIGESTIVE ORGANS. 

CHAPTER I. 

DISEASES OF THE MOUTH. 

I find myself much embarrassed in regard to the classification 
of the diseases of the mouth most proper to adopt. So much con- 
fusion reigns amongst authors as to their nature, and consequently 
as to their nomenclature, that it is very difficult to reconcile the 
various discrepancies which exist. After much consideration, 
however, I believe that the following arrangement is the one best 
suited to the existing state of knowledge upon these affections : 

1. Simple or erythematous stomatitis. 

2. Follicular stomatitis, or aphthse. 

3. Ulcerative, or ulcero-membranous stomatitis. 

4. Gangrene of the mouth. 

5. Thrush, or stomatitis with curd-like exudation. 

ARTICLE I. 

SIMPLE OR ERYTHEMATOUS STOMATITIS. 

This form of stomatitis consists of simple diffuse inflammation 
of the mucous membrane of the mouth, unattended by vesicular 
or pustular productions, by ulceration, or by membranous exuda- 
tion. It is a disease of infrequent occurrence, except in the 
forming stage of other kinds of stomatitis, and of little impor- 
tance, seldom requiring the attention of the physician. 



154 APHTHA. 

The causes of the disease are the introduction of irritating sub- 
stances, such as hot drinks, and acrid or caustic preparations, into 
the mouth ; difficult dentition ; and probably sympathy with dis- 
ordered states of the stomach. It occurs not unfrequently as a 
secondary affection, particularly in the course of measles, scarlet- 
fever, and small-pox. 

The symptoms of erythematous stomatitis are more or less vivid 
redness of the mucous membrane, which is sometimes diffused, 
and sometimes punctuated or disposed in patches ; slight swelling 
of the same tissue ; heat, and tenderness to the touch, and in the 
act of sucking or eating. The child is generally fretful and rest- 
less, and either loses its appetite, or refuses to nurse or take food 
freely, on account of the tenderness of the mouth. There are 
seldom any general symptoms except in secondary cases, in which 
they are those of the primary affection. 

The treatment is very simple. It consists in the use of some 
demulcent wash, as gum water, sassafras pith mucilage, a little 
honey put on the tongue occasionally, and if the inflammation be 
at all considerable, in the application of some astringent prepara- 
tion. This may consist of honey and borax, two or three parts of 
the former to one of the latter, or of the following wash, recom- 
mended by M. Bouchut. R. — Mel. Rosse 3i ; Aluminis 3ss ; Aquas 
distillat. 3ss. — M. The application of any of the washes recom- 
mended is best made by means of a thick and soft camePs-hair 
pencil : or it may be done with a soft rag, which should be dipped 
in the wash, and then conveyed into the mouth on the point of 
the finger. The remedy ought to be used several times a day. 

If signs of gastric or intestinal disorder are present, they should 
be attended to. 



ARTICLE II. 

APHTHAE. 

Definition ; synonymes ; frequency ; forms. — The term aphthae 
ought to be restricted to the vesicular and ulcerous form of disease 



CAUSES SYMPTOMS. 155 

of the buccal mucous membrane, in which that tissue is covered 
with an eruption of vesicles which break, and are followed by small 
rounded ulcerations. Under this title writers formerly confounded 
the affection we are now considering with ulcerative stomatitis and 
thrush. It is called by Billard follicular stomatitis, and by several 
other writers vesicular stomatitis. 

The frequency of the disease is very considerable. I shall 
describe two forms, the discrete and confluent. 

Causes. — The only causes which seem to have been ascertained 
with any degree of certainty are early age, and the process of den- 
tition ; the contact of irritating substances, particularly stimulating 
and acrid articles of food, with the mucous membrane of the 
mouth ; and the existence of some morbid irritation of the digestive 
tube, especially of the stomach. The confluent form is often 
connected with severe general disease of the constitution. 

Symptoms ; duration. — Aphthse begin in the form of small red 
elevations, having little white points upon their centres, which con- 
sist of the epithelium of the mucous membrane raised into vesicles. 
The vesicles are small in size, oval or roundish in shape, and of a 
white or pearl colour. They soon break and allow the fluid which 
they contained to escape, after which there remains a little round- 
ed ulcer, with excavated and more or less thickened edges, and 
surrounded almost always by a red circle of inflammation. The 
bottom of the ulcers is usually of a grayish colour. There is 
seldom any diffuse inflammation of the mucous membrane in this 
disease. The number of aphthse varies in the two forms. In the 
discrete variety there are but few, whilst in the confluent form they 
are of course much more numerous. They generally appear first 
on the internal surfaces of the lips and gums, and then on the 
inside of the cheeks, edges of the tongue, and soft palate. 

The discrete form is generally accompanied by symptoms of 
slight disorder of the digestive organs, consisting of thirst, acid 
eructations or vomiting, imperfect digestion, and a little constipa- 
tion or diarrhoea. The confluent form, which is much more rare, 
especially in very young infants, usually coincides, as has already 
been stated, with severe general or local disease. 

The duration of aphtha? is different in the two varieties of the 



156 APHTHA. 

affection. he discrete form generally pursues a rapid progress, 
lasting usually from the beginning to the time of cicatrization, 
between four and seven days. Sometimes, however, when the 
vesicles are formed successively, one after the other, the disease 
lasts much longer. The confluent variety pursues a much slower 
progress, and is much more difficult of cure. 

Diagnosis and Prognosis. — The diagnosis of discrete aphthae is 
not at all difficult, in consequence of their being isolated and suc- 
ceeded by small and limited ulcerations. The confluent form, on 
the contrary, may be confounded with ulcerative or ulcero-mem- 
branous stomatitis, and with thrush. From the first mentioned 
disease it may be distinguished, however, by attention to the cir- 
cumstances that that affection begins by small white patches, and 
not by pustules, as do aphtha? ; that the ulcerations which follow 
the patches are covered with true pseudo-membrane ; and that the 
white patches just spoken of appear first upon the gums, whilst 
aphtha? generally begin upon the posterior surface of the inferior 
lip, and upon the tongue. From thrush it is to be distinguished 
by the facts that that disease commences by white points which are 
not pustular, which, running together, form a creamy exudation, 
and by the absence or very small number of the ulcerations. 

Discrete aphtha? constitute a very mild disorder. They always 
recover without much difficulty. The confluent disease is more 
serious, because its progress is much slower, its cure more diffi- 
cult, and because it is often connected, as has been stated, with 
some other severe disease. 

Treatment. — Aphtha?, particularly the discrete variety, require 
in general very simple treatment. The means to be employed are 
general and topical. 

The discrete variety usually requires only topical remedies, re- 
gulation of the diet, and when there are marked symptoms of gas- 
tric derangement, the exhibition of some mild emetic, or of a laxa- 
tive dose. . The local treatment should consist of applications of 
demulcent preparations, as the mucilages of slippery elm, sassa- 
fras pith, flaxseed, marsh-mallow root, quince seeds, etc., which 
are to be used pure when there is no pain, or with the addition of 
a few drops of laudanum or wine of opium, when the mouth is 



TREATMENT. 157 

sore and tender ; the aphtha? ought to be touched occasionally 
with the mixture of borax and honey, or the aluminous preparation 
recommended for simple stomatitis. The applications must be 
made several times a day with a camel's hair pencil, a pencil made 
of charpie or cotton, or with a soft rag covering the finger. When 
the ulcers which follow the vesicles fail to cicatrise rapidly under 
the above applications, or when they are numerous and painful, 
their cure may be very much hastened and the pain quickly 
relieved, by touching them lightly with a stick of nitrate of silver, 
or a piece of alum sharpened to a point ; or we may employ a 
pencil dipped into a strong solution of nitrate of silver, or into a 
mixture of one part of muriatic acid to two of honey. 

The general treatment of discrete aphtha? need consist of no- 
thing more than the prescription of a simple, unirritating diet in 
most of the cases. If, however, the digestive apparatus is deranged, 
the case must be treated according to the symptoms ; by antacids 
or a gentle emetic, when the tongue is foul and the secretions acid, 
and by the use of a mild laxative, as castor oil, magnesia, or rhu- 
barb, when there is constipation. When diarrhoea is present, we 
should resort first to a small dose of castor oil or syrup of rhubarb, 
with the addition of half a drop to two drops of laudanum, ac- 
cording to the age of the child, and afterwards to astringents and 
opiates, as will be recommended in the article on simple diarrhoea. 

The treatment of confluent aphthce must depend on their cause. 
The local treatment is the same as that for the discrete variety, 
except that cauterization should be resorted to at an earlier period. 
When they seem to depend upon a general morbid condition of 
the constitution, as congenital debility, a scorbutic diathesis, or 
upon chronic affections of the digestive organs, they must be 
treated in the first case by properly regulated, nutritious diet, and 
by the exhibition of tonics and gentle stimulants, particularly iron, 
quinine, and small quantities of very fine old brandy ; and in the 
second case, in the manner which will be recommended for chronic 
derangements of the stomach and bowels, when I come to treat of 
the diseases of those organs. 

14 



158 ULCERATIVE STOMATITIS. 



ARTICLE III. 

ULCERATIVE OR ULCEROMEMBRANOUS STOMATITIS. 

Definition ; synonymes ; frequency. — This form of sore mouth 
is characterized by the secretion upon the mucous membrane of 
a plastic exudation in thick, yellowish, adherent patches, and 
by inflammation, erosion, or ulceration of the subjacent tissues. 
It is the same disease as the aphtha gangrenosa, and I believe 
the cancrum oris also of Underwood ; the ulceration of the 
mouth of Dewees and Eberle ; the stomatite couenneuse, and 
the ulcerative and pseudo-membranous forms of the stomatite 
gangreneuse of M. Valleix; the stomatite pseudo-membraneuse 
or diphtheritique of some writers ; and the stomatite ulcero- 
membraneuse of Rilliet and Barthez. It is the disease described 
under the title of gangrenous sore mouth by Dr. B. H. Coates 
(North American Surgical and Medical Journal, vol. ii, 1826), 
with the exception of a few cases which were what I shall treat 
of as gangrene of the mouth. It is treated of by Dr. Condie 
(I>is. of Child. 2d edit. p. 142), under the title of gangrene of the 
mouth, and partly confounded, as it seems to me, with a much 
less frequent and vastly more dangerous disease, which I shall de- 
scribe hereafter as a separate affection under that name. 

Of the different titles given above, I prefer that of ulcero-mem- 
branous stomatitis, as most expressive of the distinctive features of 
the disease. This form of stomatitis is not very frequent in pri- 
vate practice, but sometimes prevails extensively in hospitals, and 
other public institutions for children, where it often assumes an 
epidemic character. 

Causes. — The predisposing causes are epidemic influence, of 
the existence of which I believe there is no doubt ; according to 
some observers, contagion, which, however, has not as yet been 
positively shown ; and bad hygienic conditions as to cleanliness, 
ventilation, food, clothing, and habitation. It is most frequent be- 
tween the ages of five and ten years, though it may attack all ages, 



SYMPTOMS. 159 

and is more common in boys than girls. It occurs during the 
convalescence from severe diseases, as pneumonia, the eruptive 
fevers, typhoid fever, entero-colitis, and other affections of children. 

The exciting causes of sporadic cases are unknown, with the 
exception, perhaps, of the presence of a carious tooth in the mouth, 
and fracture or necrosis of the maxillary bones. 

Symptoms ; course ; duration. — The disease begins with slight 
pain and uneasy sensations in the gums, which then become 
swelled, red, bleeding when touched, and are soon after covered 
with a grayish, pultaceous exudation of varying thickness. The 
exudation extends from the gums to the internal surface of the 
lips and cheeks, and sometimes, but more rarely, to the soft palate, 
and even to the pharynx and nasal passages. The plastic deposit 
occurs in the form of small, and slightly projecting, yellowish 
patches, which approach each other, unite, and form bands of 
pseudo-membrane, somewhat uneven upon the surface, and ad- 
hering with considerable force to the tissue beneath. When the 
exudation is detached, the mucous membrane is found to be of a 
red or purple colour, bleeding, and excoriated or ulcerated. The 
ulcerations which exist under the false membrane are of various 
depths, of a grayish, livid, or blackish colour, with swelled, soft- 
ened, and livid red, or bleeding edges. Those which are formed 
upon the inside of the lips are rounded in shape, whilst those seated 
in the angle between the lips and gums, are usually elongated. 

When the disease is mild, and when it is properly treated, 
the false membranes are detached, leaving the mucous tissue 
merely excoriated, in which case it soon regains its natural condi- 
tion ; or else the ulcers which exist beneath, rapidly become 
healthy and cicatrise. In violent cases and in those badly treated, 
the inflammation, on the contrary, persists ; the pseudo-mem- 
branes increase in thickness, or if detached, are formed anew ; 
the ulcerations become deeper ; the disease extends ; and the case 
lasts an indefinite period of time. 

Other symptoms, beside those we have mentioned, characterize 
the disease. 

The breath is always more or less fetid, and in bad cases, al- 



160 ULCERATIVE STOMATITIS. 

most gangrenous. The salivary and sub-maxillary glands are 
generally more or less swelled, hard, and painful, and accord- 
ing to some authors, the surrounding cellular- tissue is in the 
same condition, though this is denied by others. The movements 
of the lower jaw are stiff and painful in severe cases. Deglutition 
is not affected unless the disease extends to the pharynx. In vio- 
lent cases there is usually a copious discharge of bloody serum, 
which flows from the mouth during sleep. When the ulcerations 
are deep and large, the tissues beneath are more or less swelled ; 
the swelling, however, rarely assumes the hard, resisting, circum- 
scribed characters, with the tense, smooth, hot, and shining ap- 
pearance of the skin which exists in true gangrene of the mouth. 
In most of the cases there is but little febrile reaction, especially 
at the invasion, though it sometimes increases afterwards if the 
disease becomes extensive. 

The disease begins, as already stated, on the gums, and unless 
limited to these parts, as sometimes happens, extends to the lips 
and cheeks. In many of the cases it attacks only one side of the 
mouth, and this is more frequently the left than the right. 

The course of the disease is usually rapid in epidemic cases, and 
in those which are properly treated. Where badly treated, on the 
contrary, it may last from one to several months, or terminate in 
gangrene of the mouth. 

Diagnosis ; prognosis. — The diagnosis is, as a general rule, 
very easy, if proper attention be paid to the characteristic features 
of the disease. It has, as already stated, been very often con- 
founded with gangrene of the mouth. The method of distinguish- 
ing between the two will be given in full in the article on that 
disease. From thrush it is to be distinguished in the manner 
which will be pointed out under that subject. 

The prognosis is favourable in the great majority of the cases. 
Sporadic cases probably always terminate favourably. The epi- 
demic disease, though rarely fatal, is sometimes so from its exten- 
sion to the pharynx and larynx, or from its termination in gan- 
grene of the mouth. Of upwards of 120 cases of this kind, 
observed by Dr. Coates at the Philadelphia Children's Asylum, in 
a period of three months, all but one recovered (Loc. cit. p. 21). 



TREATMENT. 161 

The cases which occur in the course of other diseases are not 
dangerous in themselves, but are so as the sign of great severity 
of the primary affection. 

Treatment. — The treatment may be divided into general and 
local or topical. The general treatment should consist in most of the 
cases of attention to the diet, which ought, in healthy and vigorous 
children, to be simple and unirritating, and in those who are weak 
and debilitated, nutritious and digestible. No internal remedies 
are required in the majority of the cases. If, however, the bowels 
are costive, or the child feverish and uncomfortable, a laxative 
dose may be given with advantage ; or some simple diaphoretic, 
as nitre and water, or the neutral mixture, may be used through 
the day, and a warm pediluvium or an immersion bath given in 
the evening. When the constitution is feeble, and the child weak 
or anemic, tonic remedies are indicated. The best is probably 
quinine, or one of the ferruginous preparations ; or the compound 
infusion of gentian, with addition of Huxham's tincture of bark, 
may be resorted to. If the inflammation be severe, and accom- 
panied with tumefaction and tenderness of the glands and some 
febrile reaction, it would be proper to apply a few leeches to the 
neck. 

The heal treatment is all that is necessary in a large number 
of cases. When the attack is slight, we need only to keep the 
mouth clean by means of demulcent washes, used in the manner 
recommended in the article upon aphthee, and to employ from time 
to time some mild astringent application. This may consist of 
honey and borax, of weak solutions of acetate or sulphate of zinc, 
or of sage or rose-leaf tea, with alum and honey. When the 
disease is more severe and extensive, and especially when it is 
attended with many and deep ulcerations, it should be treated with 
more energetic local applications. In such cases cauterization 
with a strong solution of nitrate of silver (9i to 3ss of water), 
or with muriatic acid, either pure or mixed with honey, should be 
resorted to. M. Bretonneau employs the pure acid, applying it 
twice in forty-eight hours in recent cases, which almost always 
cures the disease ; or, when the case is chronic, using the acid in 
the same way, with the precaution, however, of suspending its 

14* 



162 ULCERATIVE STOMATITIS. 

employment from time to time. He applies it between the teeth 
by means of a small roll of paper, and to the other surfaces with 
a mop made of rag or sponge. I would merely remark, in refe- 
rence to cauterization with these powerful preparations, that I 
have never found it necessary in private practice, having always 
succeeded with less severe and less painful remedies. 

Dr. Dewees recommends the following combination in cases of 
ulceration of the mouth, and says of it that it " has so far never failed 
us :" R. — Sulph. Cupri gr. x ; Pulv. Cinch. Opt. 3ij ; Pulv. G. 
Arab. 3i ; Mel. commun., 3ij ; Aquse font. giij. — M. et ft. sol. 
The ulcerations to be touched with the solution twice a day, with 
the point of a camel's-hair pencil. Dr. Coates (Loc. cit.), says 
that he " settled down, after various trials, in the employment of 
the following : R. — Sulph. Cupri 3ij ; Pulv. Cinchona? 3ss ; Aquse 
giv. — M. S. — To be applied twice a day, very carefully, to the 
full extent of the ulcerations and excoriations." 

Rilliet and Barthez recommend very highly the plan pursued 
by M. Bouneau at the Children's Hospital. This is to cleanse 
the mouth first, and then to apply dry chloride of lime (calx chlo- 
rinata of the pharmacopoeia), to the diseased surfaces. The ap- 
plication is made by means of a piece of rolled paper, or a stiff 
pencil, which should be moistened and then dipped into the powder 
so that some may adhere, or with the finger. The surfaces are 
to be gently rubbed with the powder, and after a few moments' 
contact, washed clean with pure water. This is to be done twice 
a day, until the ulcerations assume a clean, healthy appearance, 
after which the following mouth-wash is to be employed : 
R. — Mucil. G. Acac. 3i ; Syrup Cort. Aurant. gss ; Calc. chlo- 
rinat. Bi. — M. 

The chief danger of the disease depends on the circumstance 
that it sometimes terminates in gangrene of the mouth, to be pre- 
sently described. Any disposition to such a termination should 
be carefully watched, and the proper preventive means, consisting 
of local stimulating or caustic applications, with the internal use of 
stimulants and tonics, ought to be at once resorted to. 



GANGRENE OF THE MOUTH. 163 



ARTICLE IV. 

GANGRENE OF THE MOUTH. 

Definition ; synonymes } frequency. — Gangrene of the mouth 
is an affection which occurs chiefly in children of debilitated 
constitution. It begins generally by ulceration of the mucous 
membrane of the cheek, which after a longer or shorter time, 
runs into gangrene, and extends rapidly to the gums ; after a few 
days, if the disease be not arrested, the central tissues of the 
cheek become thickened, and indurated, an eschar forms upon the 
integument, which spreads in depth and width, until at last the 
cheek may be perforated, the whole side of the face and jaws de- 
stroyed, the teeth loosened, and the maxillary bones exposed and 
necrosed. It is known by a great variety of names : gangrasnop- 
sis, cancrum oris, gangrama oris, kanker of the mouth, gangre- 
nous erosion of the cheeks of Underwood ; necrosis infantilis, gan- 
grenous stomatitis, etc. It is a frequent disease in the hospitals for 
children in Europe, and a not uncommon one in institutions of the 
same kind in this country. It sometimes prevails endemically in 
hospitals. It is a rare disease in private practice. I have never 
yet met with a case, excepting in public institutions. 

Predisposing causes. — The disease is nearly, but not exclusively 
confined to the period of childhood. It is most common between 
the ages of three and six years ; is very rare but does sometimes 
occur in infants ; and is of nearly equal frequency probably in the 
two sexes. Unfavourable hygienic conditions constitute a strong 
predisposing cause. Children living in hospitals or any crowded 
institution ; those whose parents are poor and in want, and 
whose constitutions have been greatly deteriorated by long illness, 
by the tubercular diathesis, or by acute diseases, are particularly apt 
to be attacked. It almost always follows upon some previous 
acute or chronic disease, particularly measles, or some other 
acute exantheme ; pneumonia ; entero-colitis ; hooping-cough ; 
long-continued malarious fevers, &c. Guersent and Blache say 



164 GANGRENE OF THE MOUTH. 

{Diet, de Med. t. 28, p. 601), " The existence of some anterior 
disease is a necessary condition of gangrene of the mouth : we 
have never known it, nor has M. Baron, to occur as an idiopathic 
affection." It has been affirmed by some persons to be contagious, 
but this is exceedingly doubtful. The fact of its occurring some- 
times in an endemic form has already been referred to. It has 
been known also to prevail as an epidemic. 

The exciting causes can rarely be ascertained with any cer- 
tainty. The only one which seems to have been proved to exist 
in some instances, is the exhibition of large doses of the mercurial 
preparations, and even this is questioned by some very good 
authorities. 

Anatomical lesions. — Upon examination after death, it is found 
that the integument surrounding the mortified spot, soon runs into 
putrefaction. The lip or cheek in which the disease is seated, is 
swelled, hardened, tense, and shining, of a purple or greenish 
colour, and presents a deep, circumscribed engorgement. On the 
most prominent part of the swelling there often exists a rounded 
or oval, and distinctly limited eschar, of variable size, from that 
of a small bean, to that of a dime, or a quarter or even half dollar. 
In other instances the cutaneous slough is much larger, and ex- 
tends irregularly to different parts of the face, to the chin, neck, 
eyelids, and even to the neighbourhood of the ear, so as to 
occupy the whole of one side. Under these circumstances, the 
tumefaction is neither so considerable, nor so regular, as when the 
slough is smaller. The eschar is always black, and generally dry 
and parchment-like, and extends a third or two-thirds of a line in 
depth, or quite through the integument. The tissues beneath the 
skin are not generally implicated, though in some cases the eschar 
is detached, and there is a perforation of the cheek through which 
may be seen the alveolar processes. 

The mucous memh'ane of the mouth is always affected with 
mortification. The disease may be limited, so as to exist in the 
form of an elongated ulceration, of a dark grayish colour, situated 
in the fold where the mucous membrane is reflected from the cheek 
to the lower jaw ; or, in a larger proportion of cases, it is seated on 
the internal surface of the cheek, opposite the interval between the 



ANATOMICAL LESIONS. 



165 



alveolar processes. Sometimes the disease is much more exten- 
sive, and occupies all or a part of the internal surface of the 
cheek. In such instances the whole thickness of the mucous 
tissue is destroyed, and it presents upon its surface a blackish or 
brownish pultaceous slough, almost liquid in consistence, which 
may be scraped off with a scalpel, leaving beneath loose shreds 
of mucous membrane, without any trace of organization. The 
gums frequently participate in the disease, and are converted into 
shreds, or completely destroyed. 

The maxillary bones are sometimes, in severe cases, when the 
disease has extended to the gums, exposed, blackened, and even 
necrosed. The teeth are very often uncovered and loosened, and 
not unfrequently some are lost. The tissues between the skin and 
mucous membrane are found either hardened and infiltrated, or 
sphacelated to a greater or less extent. In the least severe cases, 
the fatty cellular tissue and the muscular structure of the cheek 
are infiltrated with serum, but preserve their organization. When 
the disease is more aggravated, the gangrene extends to these 
tissues also, and always to those adjoining the mucous membrane 
first ; so that the cellular structure beneath that membrane, and 
then the muscles, are infiltrated with a sanious fluid, and either in 
a state of sphacelus or tending thereto, whilst some of the adipose 
tissue beneath the skin is still merely infiltrated. In yet worse 
cases, the sloughs formed on the two surfaces of the cheek come 
into contact, and if their separation from the sound parts has 
taken place, a perforation is the consequence. 

The condition of the blood-vessels in the midst of the diseased 
parts has been carefully examined by Rilliet and Barthez. These 
authors state that when the tissues of the cheek are merely infil- 
trated, the vessels remain healthy, permeable, and their parietes 
are scarcely or very slightly thickened. When the vessels run 
along the edge of the slough, they are still permeable, but their 
walls are thickened, and begin to assume the appearances of the 
mortified tissues. Lastly, when they traverse the centre of the 
eschar, they can still be traced out, but their canals are found 
obliterated by coagula, in the whole extent of the mortified parts ; 
or else the coagula occupy the vessels at their points of en- 



166 GANGRENE OF THE MOUTH. 

trance into and exit from the slough, while between these points 
their walls are thickened, tend to assume the colour and softness 
of the putrefied tissues, and their canals are filled with pultaceous 
gangrenous matter. The writers quoted do not suppose that the 
obliteration of the vessels is the cause of the sphacelus, since that 
change occurs only after the death of the surrounding tissues has 
already taken place. 

The disease very rarely occurs on both sides of the mouth at 
once, though this does occasionally happen. 

The sub-maxillary glands are nearly always in their natural 
condition, but in rare instances are softened and engorged. 

Gangrene of the mouth never, or very rarely indeed, exists 
without lesions of other organs. Of these the most frequent are 
acute pulmonary affections, and after them, acute or chronic dis- 
eases of the gastro-intestinal tube, and then malarious fevers, 
pleurisy, pneumo-thorax, peritonitis, pharyngitis, and nephritis. 

Symptoms ; course ; duration. — The following account of the 
symptoms of the disease is taken chiefly from the work of Rilliet 
and Barthez. Gangrene of the mouth generally begins during 
the course or convalescence of some acute or chronic disease, 
by ulceration, aphtha?, or phlyctense, of the mucous membrane, 
and in rare instances, by oedema of the substance of the cheek. 
At the same time the face is pale, and usually continues so 
throughout the disease ; the nostrils and eyelids are often in- 
crusted, and the latter infiltrated or sunken, and surrounded by 
bluish circles ; the lips are swelled and covered with scabs, or 
dry. The breath of the child is fetid from the beginning, and 
as the disease progresses becomes gangrenous. There is but 
little fever at first, unless the case be accompanied by some acute 
disease : the pulse is commonly frequent and small in the begin- 
ning, rising gradually from 80 or 90 to 100 or 120, and becom- 
ing insensible towards the end ; in cases occurring in the course 
of other diseases, the pulse rises sometimes to 120 or 140, and is 
larger and fuller. The child is generally languid and quiet at 
first, or more rarely, cross and peevish. The strength may be 
either lost entirely, merely diminished, or the patient may retain a 
sufficient amount of force to sit up and observe what is going on 



SYMPTOMS. 167 

around, and even to leave the bed the day before death. Half of 
the children observed by Rilliet and Barthez, in whom this symp- 
tom was noted, sat up in bed until within a few days of the fatal 
termination. In most cases but little complaint is made of pain in 
the mouth, though in some it is said to be severe. 

The ulceration already spoken of as forming the first symptom 
of the disease, is generally of a grayish colour, and resembles 
very closely those which exist in the ulcero- membranous form of 
stomatitis. It may be seated either on the gums, in the fold formed 
by the junction of the cheek or lip with the gum, or on the inside 
of the cheek, opposite the space between the alveolar processes. 
It may present a gangrenous appearance from the first day, or not 
until after two or three days ; or lastly, it may pass through the 
stages characteristic of ulcerative stomatitis, and terminate in the 
affection under consideration. Dr. B. H. Coates (Loc. cit.) de- 
scribes under the title of gangrenous sore mouth of children, the 
ulcero-membranous form of stomatitis, and a few cases of gan- 
grene, and states that three or four children out of 120 affected 
with ulcerated gums, " suffered small spots of mortification, and 
one, by the delay arising from the tardy report of a nurse, suffered 
necrosis in a portion of an alveolus." 

The ulcerations just described assume the following appearances 
as the gangrenous nature of the malady developes itself. They 
become grayish, and then dark in colour, bleed easily when 
touched, and are covered with pultaceous sloughs, exhaling a cha- 
racteristic fetid odour. The gangrene extends to the neighbouring 
parts, from the gum to the cheek, or from the cheek to the gum, 
and implicates at last the whole side of the mouth, or of the lower 
lip. At the same time the affected cheek or lip undergoes a cir- 
cumscribed infiltration, which is at first rather soft, but becomes 
afterwards firmer, and forms at last a hard and rounded knot or 
tumour in the centre of the cheek, which is now tense, shining, 
and pale, or marbled with purple spots, while the slough on the 
inside is of a brownish colour, more extended in size, and some- 
times surrounded by a dark ring. The hard tumour of the cheek 
just described, usually appears between the first and third day 
after the sphacelation of the mucous membrane, though in some 



168 GANGRENE OF THE MOUTH. 

instances, not until a later period. It is formed, as stated in the 
account of the anatomical lesions, by engorgement of the cellular 
and adipose tissues. The child, at this stage, is still able to sit up 
in bed and take notice, or shows evident signs of weakness and 
depression ; the face is swelled, and destitute of expression in the 
affected side ; a bloody or dark-coloured saliva runs from the 
mouth, which is partially open ; the appetite is not entirely lost in 
all cases, the patient still demanding and taking food ; vomiting is 
rare, but diarrhoea is almost always present ; the thirst is gene- 
rally intense ; the skin is warm and feverish, natural, or too cool, 
and almost always dry, the differences depending probably more 
upon the concomitant disease than upon the mouth-affection. The 
respiration is natural or altered according to the nature of the 
primary disease, which is, as already stated, in the majority of 
the cases, a pulmonary affection. The intelligence is generally 
undisturbed, though in some rare cases there is insomnia, delirium, 
or piercing cries. 

If the disease continues to progress, as it almost always does 
when it has reached the stage I am describing, there appears in 
many, but not all the cases, (8 of the 21 observed by Rilliet and 
Barthez,) a slough or eschar upon the most prominent and dis- 
coloured part of the swelling of the integument of the cheek or 
lower lip. This generally makes its appearance between the 
third and sixth days of the disease, but in other cases, as early as 
the second, or not before the twelfth, or even later. The skin, at 
the point where the eschar is about to form, becomes purple, and 
then black ; sometimes a phlyctsena makes its appearance, which 
is very soon converted into a small, dry, black slough. This, 
if not limited by a process of separation from the living tis- 
sues, becomes larger and larger by the extension of the spha- 
celation, until it may, as already stated, embrace the whole side 
of the face. In grave and fatal cases, the gangrene sometimes 
extends to all the tissues of the cheek, and meeting, at last, 
the disease which had commenced on the inside of the mouth, 
occasions a perforation through which may be seen the teeth, 
alveolar processes, and the whole interior of the buccal cavity. 
In such instances as these, one of which I saw in the Pennsylvania 



SYMPTOMS DURATION COMPLICATIONS. 169 

Hospital, the appearance presented by the child is, as may well 
be imagined, sad and sickening to behold. Even under these 
circumstances, however, with the cheek perforated, the edges of 
the opening irregular and covered with shreds of dead tissue, the 
gums destroyed, the teeth loosened, and the maxillary bones ex- 
posed, blackened, and perhaps necrosed ; with a dark and fetid 
sanies flowing from the mouth or perforation, and a putrefactive 
smell infecting the air around, the child is said to retain, in some 
instances, its strength, so as to sit up in bed, ask for food, and 
drink with avidity. In other cases, on the contrary, the patient, 
at this stage, is exhausted to the last degree, and refuses both food 
and drink. During the closing stage of the disease, there is gene- 
rally profuse diarrhoea, rapid emaciation, dry skin, small, rapid 
pulse, and at last death in a state of utter prostration. 

In favourable cases the recovery may take place in the early 
stage, before the integument becomes involved, and while the gan- 
grene is limited to the mucous membrane, or at a later period, 
after the slough has separated. In the first instance the child 
generally recovers without deformity, though I saw one case in 
which necrosis of about an inch of the front of the inferior maxilla 
took place, without any loss of the soft parts. When the child 
recovers after the formation of the cutaneous slough, a very rare 
event, the gangrene ceases to extend, the eschar separates and is 
cast off, the edges of the opening assume the appearances of a 
healthy ulcer, and after a length of time, approach each other and 
cicatrise, leaving generally a large uneven, discoloured scar, like 
that of a burn, which remains through life a horrid deformity. 

The duration of the disease varies according to its termination. 
When this is unfavourable, which happens in much the larger 
proportion of cases, death usually occurs about the end of the first, 
or in the course of the second week, though it has been known to 
occur at a later period. In favourable cases, the duration is com- 
monly longer, particularly if a cutaneous eschar has been pro- 
duced, as the separation of the slough, and cicatrization of the 
ulcer which remains, requires a tedious and slow process on the 
part of nature. 

Complications are very apt to arise in the course of the disease. 

15 



170 GANGRENE OF THE MOUTH. 

The most frequent is pneumonia. Guersent and Blache state that 
it exists in nine-tenths of the cases ; Rilliet and Barthez found it in 
19 out of 21 ; of the 19 it began in 8 during the progress of the 
gangrene, and apparently under the influence of the latter, whilst 
in the remaining cases it existed before, and acted perhaps as pre- 
disposing cause to the affection of the mouth. Another and more 
dangerous complication is the occurrence of gangrene in other 
parts of the body, particularly the soft palate, pharynx, oesophagus, 
anus, and more frequently the vulva and lungs. 

Diagnosis. — Some authors have described as identical affec- 
tions, under the title of gangrenous stomatitis, the disease under 
consideration, and the one already treated of as ulcero-mem- 
branous stomatitis. This has been done particularly by M. Tau- 
pin, who is followed in his description by M. Valleix {Guide du 
Med. Prat. t. iv). It seems clear to me, moreover, that Dr. B. H. 
Coates, in his very valuable paper on the " gangrenous sore mouth 
of children" (Loc. cit.), and Dr. Condie, in his article on " gan- 
grene of the mouth," mingle in their descriptions the two diseases 
referred to. I cannot but think, however, that the differences be- 
tween them as to frequency, symptoms, course, amenability to 
treatment, and termination, which are fully pointed out in the 
diagnostic table below, and lastly the example of MM. Baron, Bil- 
lard, Guersent, and Rilliet and Barthez, and Dr. G. B. Wood, fully 
warrant me in regarding them as different and distinct diseases. 

The diagnosis of gangrene of the mouth is, in most cases, very 
easy. The ulceration of the mucous membrane, followed by gan- 
grene ; the deep-seated induration of the cheek, at first pale on the 
outside, then dark-coloured, and terminating after a time in a cha- 
racteristic slough ; the course of the malady, and the nature of the 
general symptoms, will generally prevent any difficulty in the re- 
cognition of the disease. 

From stomatitis it may be distinguished by attention to the 
points laid down in the following table, taken from Rilliet and 
Barthez : — 



DIAGNOSIS PROGNOSIS. 



171 



Stomatitis. 



Gangrene. 



Begins by ulceration or by pseudo- 
membranous plastic deposit. 

Odour very fetid and sometimes 
gangrenous. 

But little extension of the local le- 
sion, which always retains the same 
appearances. 

But little swelling of the cheek or 
lips, or simply oedema of those parts, 
without deep-seated induration, ten- 
sion, or unctuous appearance. 

Salivation rarely so considerable as 
to flow from the mouth; when present 
sometimes sanguinolent ; never mixed 
with shreds of gangrenous tissue. 

Never an eschar on the exterior. 

Never complete perforation of the 
soft parts; denudation of the bones 
never occurs ; loss of the teeth very 
rare. 

Course of the disease slow when left 
to itself; recovery rapid under the in- 
fluence of treatment. 



Begins by ulceration, which is some- 
times gangrenous from the first, or by 
oedema of the cheek. 

Odour always gangrenous. 

Considerable and rapid extension: 
the tissues assume a peculiar dark- 
grayish tint. 

Extensive swelling and oedema of 
the cheek, with deep-seated induration, 
tension, unctuous appearance, purple 
spots. 

Salivation abundant; constant es- 
cape of fluid, at first sanguinolent, af- 
terwards putrefactive. 

Often an eschar upon the cheek or 
lips. 

Perforation of the soft parts fre- 
quent ; denudation of the bones con- 
stant; loosening of the teeth constant, 
and their loss frequent. 

Course rapid, and fatal termination, 
as a rule, when the disease is left to 
itself, and in spite of all treatment. 



Gangrene of the mouth may be confounded with malignant pus- 
tule. The method of diagnosis has been drawn by M. Baron in 
the following words : " Malignant pustule always begins on the 
exterior; affects the epidermis first, and extends successively to 
the corpus mucosum, chorion, and subjacent parts ; whilst, on the 
contrary, the gangrene under consideration attacks the mucous 
membrane first, then the muscles, and lastly the skin." 

Prog?wsis. — The prognosis of true gangrene of the mouth is 
exceedingly unfavourable. The great majority of the subjects 
perish in spite of all that can be done. Dr. Coates (Loc. cit. p. 
14) says that a black spot on the outer surface of the swelling 
" has always been in my own experience, the immediate harbinger 
of death. It is proper to state, however, that I have heard it said, 



172 GANGRENE OF THE MOUTH. 

that cases had recovered in this city, in which the gangrene had 
produced a hole through the cheek." Rilliet and Barthez state 
that " death is the ordinary termination of gangrene of the mouth ; 
though there are instances of recovery on record." Of 29 cases 
analyzed by them, only 3 recovered. Guersent and Blache (Loc. 
cit. p. 596) state that unless arrested in the formative stage, it 
ends fatally almost constantly in from five to ten days, and fre- 
quently before perforation has taken place. Of 36 cases observed 
by M. Taupin in the Children's Hospital, at Paris, not one escaped. 
(Guersent and Blache, Loc. cit. p. 597.) The authors of the 
Compendium de Medecine Pratique, say of this disease (t. i, p. 
632), "Death is the almost inevitable termination." Dr. Mar- 
shall Hall (Edin. Med. and Surg. Journ. xiv, p. 547), reports six 
cases of the disease, two of which followed measles, one repeated 
attacks of pneumonia, one fever (type not mentioned), one worm- 
fever, and one typhus fever. All but one, the case occurring in 
the course of typhus fever, in a girl twelve years old, died. This 
girl recovered, with, however, falling-in of the right cheek, " a 
frightful chasm" on the left side of the mouth, and caries of a por- 
tion of the alveolar process, palate bone, and second molar tooth. 
Recoveries sometimes occur, however, as in the case mentioned by 
Dr. Hall, after perforation, but nearly always with terrible defor- 
mities, with adhesions of the walls of the mouth to the jaws, with 
incurable fistula?, &c. 

The prognosis is more favourable in private practice than in 
hospitals. The favourable circumstances in any case are : good 
hygienic conditions ; vigorous constitution of the child ; the ab- 
sence of dangerous concomitant disease ; the continuance of appe- 
tite and strength ; and a disposition to limitation and separation of 
the slough. Unfavourable symptoms are : weak and debilitated 
constitution of the patient; severe co-existent disease; piostration 
of the strength ; and extension of the sloughing process. 

Treatment. — The reader needs only to refer to the remarks on 
prognosis to be assured that no treatment as yet discovered promises 
much success. I would call attention also to the following state- 
ment, — that the remarks about to be made apply only to true gan- 
grene of the mouth, and not to all the cases described by some 



TREATMENT. 173 

writers under the title of gangrenous sore mouth or even under 
that of gangrene of the mouth; since, as already stated, they con- 
found together true gangrene and ulcero-membranous stomatitis. 

The treatment is divided into heal and general. The local 
treatment recommended by the French writers, consists in the cau- 
terization of the sloughing parts with one of the mineral acids, 
with nitrate of silver, or with the actual cautery. This is the 
plan proposed by MM. Billard, Baron, Guersent and Blache, Bar- 
rier, Rilliet and Barthez, Bouchut, and Valleix. The authors of 
the Bibliotheque du Medicin Praticien remark, however, that nearly 
all the patients subjected to cauterization die, and that of the small 
number saved, there are as many who had not been subjected to 
that treatment, as there are of those to whom it had been fully 
applied. They wonder, therefore, that recent authors continue to 
repose the same confidence in it, as did their predecessors. " For 
us," they say, " we are of opinion that cauterization exerts but 
slight influence, if it have any at all, and it is greatly to be de- 
sired that the zeal of practitioners might discover some more 
efficacious remedy." (Loc. cit. t. v, p. 551.) 

It is very important to make use of the caustic application as 
early after the beginning of the sphacelus as possible, for if it be 
allowed to spread to any considerable depth or extent, there is 
scarcely a hope of arresting it by any means. Guersent and 
Blache recommend pure nitric, sulphuric, or muriatic acid ; Rilliet 
and Barthez propose the acid nitrate of mercury, muriatic, sul- 
phuric, or acetic acid ; M. Valleix proposes the treatment employed 
by M. Taupin, which is to remove the pseudo-membrane and a 
part or the whole of the gangrenous eschar with scissors, to make 
some scarifications upon the healthy parts, to apply pure muriatic 
acid, and after the fall of the slough, to make use of dry chloride 
of lime (calx chlorinata). The acid most generally employed is 
the muriatic. The local treatment proposed by Rilliet and 
Barthez is the following : as soon as the ulcerations assume a 
gangrenous appearance, to touch them with a brush or sponge 
dipped into acid nitrate of mercury, or pure muriatic acid, the 
brush to remain in contact with the sloughs for a few instants, 
and then to be applied rapidly around and on the parts beyond 

15* 



174 GANGRENE OF THE MOUTH. 

them. After this cauterization, an application is to be made of 
dry chloride of lime (in the manner recommended in the article 
on ulcero-membranous stomatitis), which is to be left in contact 
with the sloughs for a few minutes, when the mouth must be 
thoroughly washed with a strong jet of water from a syringe. 
The cauterization and use of the chloride of lime are to be re- 
sorted to twice a day, and the mouth washed three or four times 
in the interval with large injections of simple water, barley water 
mixed with honey of roses, or better still, with a strong decoction 
of cinchona. If the case goes on favourably, and the sloughs 
separate, the cauterizations are to be suspended, and the chloride 
of lime alone employed. If, on the contrary, a slough forms on 
the outside of the cheek, a crucial incision must be made into it, 
and a brush charged with the same caustics introduced between 
the cuts ; powdered cinchona is then placed in the openings, and 
retained there by a piece of diachylon plaster, or by pledgets of 
charpie, dipped in a solution of soda. This treatment is to be 
continued until the slough separates, when the edges of the wound, 
and all the diseased parts that can be reached, are to be cauterized. 

In applying escharotics to the mouth, certain general precau- 
tions are required, of which it is necessary to give some account. 
When they are used upon the inside of the cheek, a spoon must 
be introduced into the mouth, with the concavity directed towards 
the alveolar processes, in order to preserve the teeth and tongue 
from being touched. When the application is made upon the 
gums, the cheek should be drawn to one side by an assistant, and 
the tongue pushed out of the way with the finger, or a spoon. 
If the acid happens to touch the teeth or tongue, it must be in- 
stantly washed off. The mouth ought always to be thoroughly 
cleansed with water immediately after the cauterization, to remove 
any superabundance of acid. 

The kind of brush most suitable for the application of the 
mineral acids is one made of charpie, strongly tied to a solid 
handle. The sponge mop, which is sometimes used, is made by 
fastening a small piece of fine sponge to the end of a stick. 

Guersent and Blache recommend that the acid be applied to 
the slough every hour, until the sphacelus ceases to extend. They 



J 



TREATMENT. 175 

state that this plan is sometimes advantageous when the gangrene 
is confined to the gums only, but that it is generally powerless 
when the disease has extended to the cheek, or has implicated the 
deep-seated tissues. Under the latter circumstances, and when 
the inefficacy of caustics has been shown by trial, they propose 
the use of the actual cautery, as recommended by M. Baron and 
other distinguished practitioners, and which, they add, has afforded 
them some brilliant results in very bad cases. 

M. Barrier advises that we should accurately expose the dis- 
eased parts by crucial incisions, and apply the escharotic to all the 
parts forming the limits of the gangrene, in such a way that the 
tissues already disposed to slough shall be thoroughly cauterized, 
while those a little beyond are so in a less degree. 

The English writers, and those of our own country, seem rather 
less disposed than the French, to make use of powerful escharo- 
tics, and lay more stress upon the general treatment. Under- 
wood, following Mr. Dease of Dublin, advises that " the parts 
should be washed and likewise injected with muriatic acid, in 
chamomile or sage tea, and afterwards dressed with the acid, 
mixed with honey of roses, and over all a carrot poultice." Dr. 
Symonds (Libr. of Pract. Med. vol. hi, p. 23,) directs the cheek 
to be frequently rubbed with a stimulating embrocation of cam- 
phorated oil and ammonia, on the first appearance of the swelling, 
and in the intervals to be kept moist with a tepid lotion containing 
muriate of ammonia and alcohol. On the slightest appearance of 
an eschar upon the interior of the mouth, it is to be touched with 
solid nitrate of silver, or strong muriatic acid. If sloughing has 
already commenced, the nitrate of silver lotion is said to be the 
best application. The mouth is to be frequently washed or 
syringed with a solution of chloride of soda, and when morti- 
fication has taken place, we are to endeavour to prevent it from 
spreading, by carrot, or fermenting poultices. Maunsel and Evan- 
son say that the early application of muriatic acid, undiluted, or 
mixed with one or two parts of honey, is the only efficient appli- 
cation in these forms of gangrene. Dr. Gerhard {Libr. of Pract. 
Med. vol. hi, Am. Ed., p. 24), says, " the best local applications 
are the nitrate of silver, if the slough be small in extent ; if much 



176 GANGRENE OF THE MOUTH. 

larger, the best escharotic is the muriated tincture of iron, applied 
in the undiluted state ; after the progress of the disease is arrested, 
the ulcer will improve rapidly under an astringent stimulant, 
such as the tincture of myrrh, or the aromatic wine of the French 
Pharmacopoeia." Dr. Dunglison (Pract. of Med. vol. i, p. 36) 
recommends the application with a brush, of a mixture of equal 
parts of creasote and alcohol, after incisions have been made 
through the gangrenous parts. Dr. Condie (Loc. cit. p. 150) 
states that he has found a strong solution of sulphate of copper, 
(thirty grains to the ounce of water,) applied very carefully twice 
a day, to the full extent of the gangrenous ulceration, by far the 
most successful lotion. 

It seems to me very clear, after the study of the treatment re- 
commended by the different writers quoted above, that the most 
important part of the local management of the disease, is the 
early application of some escharotic substance to the ulcerations, 
or to the mortifying parts ; the best escharotic is probably pure 
muriatic acid. This should be made use of twice or three times 
a day, observing the precaution to wash the mouth immediately 
afterwards, with water by means of a syringe. Later in the dis- 
ease, when the gangrene has extended to the skin, the use of 
escharotics, or of the actual cautery, is still recommended by 
many writers, but opposed by others. I confess I should be in- 
clined to prefer at this stage, the use of muriated tincture of iron, 
as recommended by Dr. Gerhard, of strong lotions of sulphate of 
copper, of solutions of nitrate of silver of moderate strength, or 
of the dressings of muriatic acid and honey of roses, as proposed by 
Underwood, in connexion with carrot and fermenting poultices, as 
recommended by Underwood and Symonds. Throughout the 
course of the disease the mouth ought to be frequently cleansed 
by washing or injecting with solution of chlorinated soda, mixed 
with eight parts of water, which corrects at the same time the 
terrible fetor of the disease. 

General Treatment. — All writers recommend the use of tonics, 
stimulants, and nutritious diet, unless the presence of high fever, 
or the state of the digestive organs, seem to contra-indicate their 
employment. Without personal experience on which to found 



GENERAL TREATMENT. 177 

such an opinion, but from a consideration of what I have seen 
most successful in other forms of gangrene, as that following 
accidents and surgical operations in deteriorated constitutions ; 
from what proved effectual in a case of idiopathic gangrene of the 
vulva, in a child ten years of age, which came under my charge ; 
and from what is necessary in analogous conditions of the consti- 
tution when labouring under typhoid and cachectic diseases, I am 
induced to believe that the general treatment must be of as great 
or nearly as great importance as the local, and that the steady and 
persevering use of tonics, stimulants, and of the most strengthening 
diet, should always be insisted on from the earliest period, whether 
fever be present or not. The quantity of stimulants and the amount 
of food, ought, it seems to me, to be measured only by the capacity 
of the digestive organs to receive and assimilate them. Of the 
tonics, the best is quinine, which may be given suspended in syrup, 
in doses of a grain four or five times a day, to a child three or 
four years old. The most suitable stimulants are very fine old 
brandy, Madeira wine given in considerable quantities, and, if the 
stomach is sure to receive it well, carbonate of ammonia, or better 
still, the aromatic spirits of hartshorn. The diet must consist of 
milk, made into punch with brandy, wine whey, the yelks of eggs 
beaten up with wine, rich soups, animal jellies, and, if the child 
wishes it, of tender meat finely minced. 

The room in which the child is placed ought to be large, if pos- 
sible, and at all events, thoroughly ventilated. 



ARTICLE V. 

THRUSH. 

Definition ; synonymes ; frequency ; forms. — Thrush is a de- 
posit upon the mucous membrane of the mouth, of a whitish or 
grayish-yellow exudation, of a soft, cheesy consistence, at first 
adherent, and afterwards spontaneously detached, and generally 
unaccompanied by ulceration of the tissue beneath. This consti- 
tutes the whole disease in some cases, no other lesion being dis- 
coverable ; whilst in other instances, and probably in the great 



178 aphtha. 

majority, it is connected with some more or less serious general or 
local affection. It is the disease described under the title of aphthce 
or thrush, by Underwood and Eberle ; of aphthae, by Dewees ; of 
erythematic stomatitis with curd-like exudation, by Dr. Condie, 
and of aphtha lactantium, aphtha lactamen, and aphtha infantilis 
of older writers. It is the muguet of the French. 

The frequency of the disease is very great in hospitals for chil- 
dren. It is common also amongst the children of the poor, and 
comparatively rare in the middle and upper classes of society. It 
occurs under two forms, the idiopathic or primary, and sympto- 
matic or secondary. By the first is meant the form in which the 
affection of the mouth is the only perceptible lesion ; by the second, 
that in which disease of other organs, or of the constitution gene- 
rally, precedes the buccal exudation. 

Causes. — Predisposing causes. — The disease occurs at all ages, 
but is by far most common during the two first months of life. 
Altered health from any cause, deficient ventilation, and want of 
cleanliness, strongly predispose to the production of thrush. Much 
difference of opinion exists as to the nature of the connexion be- 
tween enteritis and thrush, especially since the publication of the 
researches of M. Valleix, who thinks that the latter disease is 
almost always the consequence of the former, and who doubts the 
existence of purely local cases of thrush. MM. Trousseau and 
Delpech, on the contrary, (Journ. de Med., de MM. Beau et 
Trousseau, January, Feb., April, May, 1845,) report 14 cases out 
of 58, in which there were neither gastric nor intestinal complica- 
tion, and others in which enteritis did not occur except as a conse- 
quence of thrush. They state, however, that though enteritis does 
not exist in all cases, and is a simple complication in others, it is 
sometimes the true cause, the sole origin of the disease. Again, 
Dr. Berg, in a very accurate and careful history of the disease, 
{Brit, and For. Med. Rev. October, 1847, p. 429,) in which he 
asserts and endeavours to show its cryptogamic nature, states 
" that both the local and general symptoms which accompany 
thrush in the child are, in most cases, immediate or secondary 
consequences of the presence of the parasite, and not to be re- 
garded as the causes of that fungoid vegetation." It is believed by 



CAUSES. 179 

many observers to be contagious. This opinion is rendered doubt- 
ful, however, by the assertions of MM. Baron, Billard, Guersent, 
and Valleix (Loc. cit. t. iv, p. 63), that they have known children 
in health to be fed with the same spoon which has been used for 
others affected with the disease, without their contracting it. M. 
Bouchut, on the contrary, and Dr. Berg {Loc. cit.), both of whom 
believe in the cryptogamic nature of thrush, assert it to be conta- 
gious. Dr. Berg is of opinion that it is " conveyed from one pa- 
tient to another by sporules or fragments of sporules, in the dried 
state, floating in the atmosphere, but that it still more frequently 
is propagated by the bottles from which children with thrush have 
been fed, or by the nipple, especially where, as in many hospitals, 
two children are suckled by one nurse." This gentleman made 
many experiments in order to decide this question, all of which 
proved favourable to the idea of contagion. 

Of various predisposing causes which have been cited as pro- 
ductive of the disease, the ones most generally admitted are the 
use of artificial diet, particularly one consisting of farinaceous 
substances, and in children who are suckled, an unhealthy state 
of the nurse's milk. To show the truth of these assertions, I 
make the following quotations. Underwood says : " A principal 
remote cause of this disease seems to be indigestion, whether 
produced by bad milk, or other unwholesome food, or by the 
weakness of the stomach." Dewees remarks that " children 
fed much upon farinaceous substances, are especially exposed to 
the attacks of this disease, particularly when their food is sweet- 
ened with brown sugar or molasses." Dr. Eberle says : " Un- 
wholesome and indigestible nourishment, and over-distension of 
the stomach, during the early stages of infancy, almost inevitably 
lead to the occurrence of aphtha? (thrush). Bad and old milk, 
and thick farinaceous preparations sweetened with brown sugar or 
molasses, are especially apt to give rise to the disease." Much 
influence is ascribed by Dr. Berg to the operation of artificial food 
in favouring the growth of aphthse. M. Valleix {Loc. cit. p. 60) 
who has studied the subject with the greatest care and attention, 
says that amongst the hygienic conditions which may act as pre- 
disposing causes " one alone has seemed to me to exert a positive 



180 APHTHJE. 

influence, and this is improper alimentation." He adds that since 
the publication of his " Clinique" he has several times met with 
cases of thrush, " and I have always found that the children had 
been put upon feculent diet. On the other hand, I have never 
known a child to have the disease, who had been suckled exclu- 
sively during the early months of life." MM. Trousseau and Del- 
pech, in the very valuable paper on muguet (thrash) already 
quoted, say : " we would be justified, therefore, in asserting, that 
we have never known an infant to die of thrush, who had been 
suckled at a healthy breast, or whose health had not been dan- 
gerously compromised by other causes." To show in another 
mode the influence of this cause, I will state that of 29 cases of 
the disease observed by these gentlemen in children who were 
suckled, only 7, or one-fourth, died ; whilst of 22 in those who 
were not suckled, 17, or more than three-fourths, died. 

Season exerts a considerable influence upon the production of 
thrush, as M. Valleix found that more than half the cases oc- 
curred during the three warmest months of the year. 

Exciting causes. — The deprivation of the breast, and a conse- 
quent resort to artificial diet, particularly one consisting of farina- 
ceous substances, is probably much the most frequent exciting 
cause of thrush. An unhealthy state of the milk of the nurse will 
also act as an exciting cause. I have met with two cases of the 
disease, one of them fatal, which appeared to depend upon the 
latter circumstance. Dr. Berg believes that prolonged sleep from 
any cause disposes to the disease, by favouring the growth of the 
parasite, or by so changing the secretion of the mucous membranes 
of the mouth, as to render them important agents in augmenting 
the disorder. An acid state of the buccal secretion is cited as a 
cause by many authors, and is clearly proved to exist in a great 
many instances. 

Anatomical lesions. — The characteristic exudation is formed 
upon the mucous membrane of the mouth, pharynx, oesophagus, 
and in very rare cases, of the stomach and intestines. It is a curi- 
ous fact, and a very important one, insisted upon by MM. Trous- 
seau and Delpech and other observers, that the false membrane 
never extends to the nasal or air-passages ; and they call attention 



ANATOMICAL LESIONS. 181 

to the singular difference in this respect between the affection un- 
der consideration and diphtheritic inflammation, which attacks 
almost exclusively the nostrils, pharynx, larynx and bronchia. 

Lesions of the digestive mucous membrane are met with in 
nearly all the cases. M. Valleix states that softening of the gas- 
tric mucous membrane is almost constant, and that it is often ac- 
companied by redness and thickening. The authors cited above 
are of opinion that the gastric lesions have been greatly exagge- 
rated, and assert them to be much the same as what exist in other 
diseases foreign to the digestive apparatus. Various morbid altera- 
tions of the mucous membrane of the intestines exist in nearly all 
fatal cases. This fact is acknowledged as well by MM. Trousseau 
and Delpech, who deny the invariable connexion of these altera- 
tions with thrush, as by M. Valleix, who asserts the connexion 
almost without reserve. In nearly all cases the mucous mem- 
brane of the large intestine presents some of the following lesions, 
which are mentioned in the order of their frequency ; thickening, 
injection, softening, or ulceration. In the ileum are found, in a 
great many cases, injection, softening, or thickening of the mucous 
membrane, unusual development of the mucous follicles, and tume- 
faction and ulceration of the glands of Peyer. 

In severe symptomatic cases a certain amount of erythematous 
inflammation is commonly found upon the skin of the buttocks 
and thighs, and ulcerations sometimes exist upon the inner ankles. 
Traces of inflammation sometimes, but very rarely, exist in the 
membranes of the brain, and the lungs not un frequently present 
the lesions of secondary pneumonia. Before leaving this part of 
the subject, I may remark that in the few cases I have met with in 
private practice, no ulcerations occurred upon the malleoli, and 
the erythema was observed only in the neighbourhood of the anus. 

Dr. Dewees describes the autopsy of a child who died about the 
end of the first month of life, of what he designates as aphtha?. 
The lesions coincide so closely with those which are characteristic 
of thrush, that I will quote the description, in order that the two 
may be compared together by the reader. " We found the whole 
tract of the oesophagus literally blocked up with an aphthous in- 
crustation, to the cardia, and there it suddenly stopped. The 

1G 



182 THRUSH. 

inner coat of the stomach bore some marks of inflammation, as 
did several portions of the intestines ; but not a trace of aphthae 
could be discovered below the place just mentioned." In the pre- 
vious description of the case, he says that coat after coat of aphthae 
were thrown off, and each new crop appeared to be more abun- 
dant, and less amenable to remedies. (JDewees on Children, p. 304- 
305.) 

Dr. Eberle says : " I have myself had an opportunity of exa- 
mining the body of an infant, that had died of this disease (aphthae 
or thrush). In this case the aphthae were very distinct, through- 
out the whole course of the oesophagus. The stomach and 
bowels presented nothing that bore any resemblance to this erup- 
tion ; but there were decided marks of inflammation in the mu- 
cous membrane of the small intestines, with a vast number of 
minute superficial ulcerations, and larger patches of softening of 
this tissue, throughout the colon, and lower part of the rectum." 
{Diseases of Children, p. 172-173.) 

Symptoms. — I shall first describe the characters of the exuda- 
tion, and then proceed to the consideration of certain general and 
local phenomena which exist to a greater or less extent in both 
forms of the disease. 

The mucous membrane of the mouth is often somewhat red, dry 
and tender for a longer or shorter time, (generally from one to 
three days,) before the appearance of the exudation, and at the 
same time the papillae of the tongue swell and become protuberant. 
Next the exudation shows itself in the form of small, whitish points, 
sometimes on the tongue first, and in other cases on the inside of 
the lips, whence it extends to the cheeks, in idiopathic mild cases, 
and to the roof of the mouth, soft palate, pharynx and oesopha- 
gus in the grave, symptomatic form. The points of false mem- 
brane first deposited, rapidly increase in size and thickness, so that 
in from one to three or four days, they assume the form of large 
patches, or a continuous membrane, which covers the whole or a 
considerable portion of the cavity of the mouth. When the exuda- 
tion is recent, it is thin, and its surface smooth ; when, on the con- 
trary, it has been longer deposited, it becomes thicker, and its sur- 
face is rough. It is at first of a milk white or pearly hue, but when 



SYMPTOMS. 183 

undisturbed assumes a grayish or yellowish colour. It is soft in 
consistence, breaking down under the finger like cheese, and pre- 
sents no traces of organization to the naked eye. It adheres to 
the mucous membrane with considerable tenacity, at first, but be- 
comes looser after a while, and is detached spontaneously at last 
without any lesion of the tissue beneath. 

The foregoing description applies to the exudation as it appears 
to the unassisted eye. I pass next to give an account of the cha- 
racters it presents, when subjected to microscopical examination. 
These are such as have induced several observers to assert that 
the deposit consists of a true cryptogamic growth. Dr. Berg (Joe. 
cit.) states that the white coating of the exudation consists of epi- 
thelium, thickened by the swelling of its constituent cells ; from 
the epithelium there springs a parasitic fungus in greater or less 
quantity, so that the chief portion of a patch of aphthae (thrush) is 
composed either of epithelium or else of the parasitic growth. 
Under a magnifying power of from 200 to 300 diameters, an 
aphthous crust is seen to consist of epithelial cells, with a more or 
less interweaved coat of fibres, and a variable number of spherical 
or oval cells, without any sign of exudation-corpuscles, but only a 
small quantity of molecular albuminous deposit. " We can often 
trace the successive development of these cells from a spherical 
one of the smallest size, to an oval cell, and thence to a filament; 
and we have no doubt ourselves that the smaller cells are sporules, 
out of whose development the larger oval cells are formed, and 
finally, the filaments in the same manner as has been observed in 
other fungoid growths of this nature." Numerous projecting fibrils 
are observed in the circumference of an aphthous crust when sub- 
mitted to the microscope, but these are rendered infinitely more 
clear by a weak solution of potash, which dissolves the albumen, 
and renders the cells of the epithelium transparent, while, at the 
same time, it diminishes their intimate cohesion, and the network 
of vegetable fibres is more plainly seen. "These fibres are cylin- 
drical, with sharply-defined dark edges, and their centres are 
transparent in transmitted light ; they arc generally equal in thick- 
ness, but at times they are, as it were, knotted together, and di- 
vided by distinct walls of separation In their interior, 






184 THRUSH. 

these fibrils often exhibit nucleated cells ; occasionally these are 
very numerous, and of small size, but at times they are larger. 
In their course the fibrils divide into numerous branches, whose 
diameter is not less than that of the original stem, and I have 
occasionally observed these ramifications to increase in thickness, 
at their free extremity, and to terminate in a club-shaped end with 
a species of cell. From the sides of the fibrils spring numerous 
sporules forming a point of departure for new ramifications. . . . 
Careful investigation has shown us that these cells are placed upon 
the sides of the fibrils, and in particular that they are congregated 
around the terminations of the latter. It must therefore be ad- 
mitted that the cells and the fibrils are both constituent parts of 
one and the same organization. When this growth vegetates un- 
disturbed, its fibrils penetrate between the layers of the epithelial 
cells, but do not extend deeper than the inferior layer, though they 
spread laterally in every direction. On the free surface of the 
epithelium, the ramifications rise above the surface, exhibiting at 
the same time an abundant fructification, which gives a yellowish 
hue to the exterior." 

I regret very much that my limits are such as prevent me 
from giving some account of the various facts and arguments 
brought forward by Dr. Berg, to prove the truth of his opinion, 
that the exudation of thrush is a parasitic growth or vegetation, 
having the epithelium of the mucous membrane for its soil. I 
must refer the reader to the very interesting review of Dr. Berg's 
work, from which we have made the above quotations, and to 
the work of M. Bouchut on the diseases of new-born children, for 
further accounts of the cryptogamic theory of thrush. 

Symptoms of the mild form of thrush. — This form is the one 
most frequently met with in private practice. It is mild in all its 
characters, and often presents no other symptoms than those con- 
nected with the mouth. These are heat and dryness, with tender- 
ness of that part. The tenderness is shown by the child's crying 
and jerking the head backwards when the finger is introduced into 
the mouth, whereas in health the infant will almost always seize 
the finger and suck it with considerable force. It is shown also 
by the refusal to take the breast, or by the difficulty with which it 



SYMPTOMS. 185 

is done, the child occasionally letting the nipple drop with a cry of 
pain, then seizing it again, and again letting go with fretting or 
screaming. In some of the cases there are various signs of dis- 
order of the digestive tube, which are, however, seldom severe. 
They consist of slight diarrhoea, the stools being at first yellow, 
and afterwards green and acid, of occasional vomiting, of attacks 
of colicky pain, and sometimes of feverishness. To show how fre-' 
quent is the occurrence of diarrhoea in thrush, and to prove also 
that it is not a necessary accompaniment of the disease, as has 
been supposed by some persons, I will quote the fact mentioned by 
Dr. Berg, that of 115 cases, in only 29 did the stools retain the 
normal yellow colour throughout the whole course of the disease ; 
while in the remaining 86 green evacuations appeared simulta- 
neously with the invasion, or supervened at a later period. We 
may cite also the cases reported by Trousseau and Delpech, of 
which only 14 out of 58 presented neither gastric nor intestinal 
complications. 

The amount of exudation is generally small in this form, and it 
rarely extends behind the soft palate. The duration is usually 
between four and nineteen days, the average being about eight or 
twelve. The termination is almost always favourable. 

Grave form. — It is under this form that the disease is most apt 
to occur in public institutions for children, and particularly in 
foundling hospitals. That it sometimes occurs also in private 
practice, will not be doubted, I think, by any who will read with 
care the descriptions of the disease given by Underwood, Dewees, 
and Eberle. I have myself met with two fatal cases in private 
practice, which presented all the symptoms described by M. Val- 
leix, as characterizing those observed by him in the foundling's hos- 
pital at Paris, with the single exception of the ulcerations upon the 
internal malleoli. They were both children of parents who had 
every comfort at their command. One died at the age of four 
weeks, in consequence of the attempt to rear it on artificial diet. 
The other perished when six weeks old, apparently from some 
unhealthy condition of the mother's milk, which seems the more 
probable from the fact that the same mother had previously lost 
two children under precisely similar circumstances ; all the chil- 

16* 



186 THRUSH. 

dren of this person were born vigorous and hearty, and did well 
for a short time, but soon after the birth, the nipples of the 
mother became dreadfully excoriated, the digestive organs of the 
infant began to give way, and death finally occurred with all the 
symptoms of fully developed thrush. I can surmise now, though 
no examination was made at the time, that the cause of the disease 
was a continuance of colostrum granules in the mother's milk. 

The most important symptoms of the grave form are the buccal 
exudation, various abdominal symptoms, particularly diarrhoea, 
vomiting, and colic, and more or less marked^/ever. The order of 
succession of the symptoms in severe thrush is not always the same. 
In most of the cases, the first symptom observed is probably 
diarrhoea, which is soon followed by fever, and in a few days by 
the appearance of the false membrane in the mouth. In a smaller 
number of instances the buccal exudation is the first symptom 
observed. ■ The characters of the exudation are much the same as 
those observed in the mild form of the disease, except that the 
membrane is thicker, covers a larger portion of the mouth, and 
generally extends to the pharynx and oesophagus. In addition to 
the plastic deposit, there sometimes exist, especially in very bad 
cases, ulcerations upon the roof of the mouth, frsenum linguse, and 
gums. These are generally few in number, and either confined to 
the mucous tissue, or they may extend to the fibrous texture be- 
neath ; the surface upon which they rest is generally softened in 
consistence ; their edges are irregular, soft, and of a whitish or 
reddish colour. The heat of. the mouth is not generally increased, 
except in very severe cases ; the mouth is moist at first, but after- 
wards becomes very dry, and from the refusal to suck the finger 
when it is introduced between the lips, and the difficulty with 
which the acts of suckling or feeding are performed, is evidently 
tender and painful. 

The symptoms depending on the enteritic affection, are tender- 
ness of the abdomen, diarrhoea, vomiting, and fever. The ab- 
domen is usually distended by flatulent collections in the bowels, 
and is more or less painful to the touch, particularly in the right 
iliac fossa and epigastrium, and in severe cases over its whole ex- 
tent. At the same time, the child evidently suffers from colicky 



SYMPTOMS. 187 

pains, as shown by restlessness, by uneasy twisting movements of 
the trunk, by kicking of the limbs, and by crying, particularly 
just before, or at the moment of the evacuations. The appetite is 
usually diminished or entirely lost. The diarrhoea comes on gra- 
dually, the stools retaining their natural colour at first, and being 
merely thinner and more frequent than natural. As the case pro- 
gresses, they become more and more liquid and numerous, and 
almost invariably of a bright green colour, and very acid. The 
green colour of the discharges, and their highly acid condition, is 
noticed by all observers. Vomiting occurs in many of the cases, 
but is less frequent than diarrhoea. In some instances it is very 
obstinate and distressing, causing the rejection of whatever 
alimentary substances the child may take. Under these circum- 
stances it has often been observed to coincide with the presence of 
a great deal of exudation upon the base of the tongue and soft 
palate, which has been supposed to act as its exciting cause. In 
other instances it is not so frequent, and as the matters ejected con- 
sist of greenish or yellowish bile, while at the same time the epi- 
gastrium is very sensible to pressure, this form of vomiting has 
been thought to depend upon gastritis. 

Fever exists in most cases, from the time that diarrhoea makes 
its appearance, and sometimes at an earlier period. It is at first 
moderate, but as the case goes on, often becomes intense, the pulse 
rising gradually from 80 or l J0, to 120, 140, and even 1G0. The 
heat of the surface, especially of the abdomen, is much increased, 
and accompanied by dryness. The feverish condition of the 
system is shown also by the restlessness and fretting of the child, 
and often by loud, frequent crying. When the exudation extends 
into the pharynx, the cry usually becomes hoarse and indistinct. 

There are two other symptoms which occur in the course of 
thrush, about which some discussion has arisen. These are the 
appearance of an erythematous redness about the anus, and upon 
the buttocks, genitals, and upper parts of the thighs, and ulcerations 
upon the internal malleoli. The erythema is stated by M. Valleix 
to precede the other symptoms in the greater number of instances, 
whilst MM. Trousseau and Delpcch deny the correctness of the 
assertion, and observed it to follow the diarrhoea in the majority 



188 THRUSH. 

of their cases. It seems to me that the latter authors are correct 
in ascribing the erythema to the irritation produced by the contact 
of the urine with the skin, which is predisposed by the cachectic 
state of the constitution, to take on inflammation from causes which 
would not affect it in its healthful condition. The erythema is 
sometimes followed by papulae, vesicles, blebs, and ulcerations, all 
of which probably depend upon the cause just referred to. The 
malleolar ulcerations are ascribed to the friction of the ankles 
against each other, a cause sufficient to produce such an effect in 
a broken down, diseased constitution, though insufficient in a 
healthy one. I may mention that I have seen the erythema several 
times in private practice, but never the malleolar ulcerations. 

During the acute period of the disease, the strength of the child 
is not much diminished, but as the case approaches its termination, 
if no favourable change takes place, the patient becomes weak 
and exhausted ; the face assumes a pale and sallow look ; the 
features are sharp and defined, and the eyes dull and surrounded 
by bluish circles. At the same time the whole body becomes 
emaciated, the skin loses its elasticity, and hangs in folds or 
wrinkles upon the limbs, and the surface assumes a dark and 
dingy hue. As the fatal termination approaches, all restlessness 
ceases, and the child lies profoundly still, or only moves the 
mouth from time to time, or utters a faint cry ; the diarrhoea 
diminishes, and the vomiting generally ceases ; the pulse becomes 
very rapid and weak, the extremities cold, and death occurs in the 
midst of profound quiet, or after a few slight convulsive move- 
ments. The duration of this form of the disease is very uncer- 
tain. It is often less than that of the mild form, since many 
children perish in the first five days after the appearance of the 
exudation. In other cases it is much longer, from a few weeks to 
two months. Relapses are not uncommon. 

Before closing my remarks upon the symptoms, it is proper 
to state that the disease sometimes occurs at the termination of 
acute local affections, as pneumonia, bronchitis, or pleurisy, under 
which circumstances, there will be, in addition to the symptoms 
peculiar to thrush, those of the malady which preceded it. 

Nature of the disease. — It is impossible, it seems to me, to dc- 



DIAGNOSIS PROGNOSIS. 189 

termine, at present, whether thrush is, as M. Valleix asserts, a 
general disease, of which enteritis and the consequent buccal exu- 
dation are merely principal phenomena ; whether, as MM. Guer- 
sent and Blache suppose, it is a superficial inflammation of the 
digestive mucous membrane, attended with a peculiar exudation as 
an effect ; or whether, as supposed by Gruby, Bouchut, and Berg, 
it is a true cryptogamic or parasitic growth. Fortunately, the 
solution of the question is not of very great practical importance, 
as the causes of the disease, its phenomena, its prophylactic and 
curative treatment, are all ascertainable by careful observation, as 
well on one supposition as the other. 

Diagnosis. — The diagnosis of thrush is rarely difficult. Aph- 
thae differ from it in their vesicular nature during the formative 
stage, in the ulcerations which follow the vesicles, and in the ab- 
sence of false membranes. From ulcero-membranous stomatitis it 
may be distinguished, by the formation in that disease of false 
membrane in layers from the beginning ; by the presence of ulce- 
rations ; by the spongy, bleeding state of the gums ; by the fetid 
breath ; and by the absence of the abdominal symptoms which 
exist in thrush. 

Prognosis. — The prognosis must depend, in great measure, upon 
the circumstances under which the disease occurs. In private 
practice, and whenever the patients are suckled by their own 
mothers, or by healthy nurses, it is seldom a dangerous affection. 
But in foundling hospitals, on the contrary, where the children are 
mostly brought up on hand, it is one of the most fatal maladies to 
which children are subject. The prognosis varies according to 
the form of the disease. The mild form is rarely fatal, while the 
grave form is fatal in the great majority of the cases. 

To show the frightful severity of the disease under certain cir- 
cumstances, I may mention that of 140 cases which occurred in 
the wards of M. Baron, at the Foundling's Hospital of Paris, only 
29 recovered ; while of 22 cases observed by M. Valleix, in the 
same hospital, but two recovered (Valleix, Loc. cit. p. 74). Again, 
M. Bouchut states that of 42 cases observed by himself, at the 
Neckcr Hospital, 14 were of the idiopathic (mild) form, all of 
which terminated favourably ; and 28 of the grave or symptomatic 



190 . THRUSH. 

form, of which 20 died, and 8 left the hospital still labouring under 
the disease. Of the 20 fatal cases, 12 presented the lesions of 
chronic entero-colitis, 4 of acute entero-colitis, 3 of pneumonia, 
and 1 of hydrocephalus. It may be stated, in conclusion, that the 
danger is greatest in private practice, when the attack occurs in a 
child fed on artificial diet ; when there is reason to suspect an un- 
healthy state of the nurse's milk ; and in proportion to the extent 
and quantity of the exudation, its resistance to treatment, and the 
severity and obstinacy of the abdominal symptoms. 

Treatment. — Prophylactic treatment. — The most certain means 
of preventing thrush are evidently to procure for the child a full, 
healthy breast of milk, to give it a good habitation, to secure for it 
perfect cleanliness, and to attend properly to its clothing. When 
it is impossible, from any cause, to obtain a nurse for the child, the 
diet ought to be most carefully regulated as to quality, quantity, 
and times of administration. 

General treatment. — It seems to me that the successful manage- 
ment of thrush must depend much more upon judicious regulation 
of the hygiene of the child, than upon any therapeutical system 
that can be devised. The most frequent cause of the disease is, 
as we have seen, artificial diet, or an unhealthy state of the nurse's 
milk. It is reasonable to conclude, therefore, that attention to the 
removal or mitigation of these and other unfavourable hygienic 
conditions, constitute one of the most important indications of treat- 
ment. 

If a child who has been attacked with thrush is suckled exclu- 
sively, the milk of the nurse ought to be subjected to chemical and 
microscopic examination, and should it be found to present un- 
healthy characters, another nurse ought to be procured as soon as 
possible. In all such cases the nurse must pay strict attention to her 
diet, avoiding all articles which she knows or suspects to disagree 
with her, and all very rich dishes. Dewees recommends that she 
should abstain from most common vegetables, except rice, and 
from all kinds of liquors, especially the fermented. 

When the disease occurs in a child who is nursed and fed alter- 
nately, and the remark about to be made applies still more strongly 
to one fed entirely upon artificial diet, the most important remedy 



TREATMENT. 191 

in the case is to procure a good wet-nurse. This is far better than 
any medical treatment that can be instituted. Often, however, it 
is impossible, and under such circumstances, the regulation of the 
diet of the infant ought to be attended to with the utmost care by 
the physician himself, who should specify its material, quantity, 
and mode of preparation. 

The best substitutes for human milk are said to be goat's or 
asses' milk. But these can seldom be obtained in this country, 
and we are obliged, therefore, to resort to the milk of the cow. 
This should never be given pure to a child under two months of 
age. It ought always to be diluted with two parts, and if the 
digestive power be weakened by illness, with three, or even more, 
parts of water. It is very important to determine the quan- 
tity of food to be given the child in every twenty-four hours. 
From various inquiries and observations that I have made with a 
view to ascertain this point, I have been led to conclude that a 
healthy infant of two or three weeks old, will receive from a good 
nurse, and digest well, about a pint of milk in twenty-four hours. 
At the end of the first month, and in the course of the second, the 
quantity taken by the child increases gradually, to about a pint 
and a half or a quart. 

The data upon which I found these assertions are the following. 
A woman whom I attended after her confinement, had a pint of milk 
measured, drawn from her breasts daily by the nurse. I asked her 
how much she thought the child, a vigorous, hearty boy, took 
during the same time. Her reply was that, judging from the fre- 
quency and vigour with which he nursed, she was quite sure he 
took as much as the nurse. I had another patient, who lost her 
child in the birth, and who, desiring to go out as a wet-nurse, kept 
up her milk by means of a breast-pump. Six weeks after her 
confinement, I had all the milk she obtained in a period of twenty- 
four hours kept for my examination. It measured just a quart. 
I made very careful inquiries in regard to the point under con- 
sideration, of a very experienced and intelligent nurse, who has 
been constantly employed in this city for thirty years back. I 
desired her to answer me accurately two questions : 1. How much 
nilk do you think a healthy mother gives to her child daily after the 






192 THRUSH. 

flow is fairly established ? 2. What quantity of nourishment do you 
give in twenty-four hours to infants that you are compelled to feed 
exclusively I The answer to the first was that she had often drawn 
more than a pint from the breasts in the twenty-four hours, in 
addition to what a healthy child took, and that she had frequently 
taken as much as three pints from women who had lost their chil- 
dren. She supposed, therefore, that a hearty child would take 
during the first two weeks, at least a pint, and much more after- 
wards. To the second question she replied : that she usually gave 
to hearty children of one, two, and three weeks old, a pint of food 
in twenty-four hours. 

We may, therefore, I think, assume as a general rule, that a 
healthy child, within the month, ought to take about a pint of 
nourishment in the time specified. 

An infant labouring under thrush would scarcely take so much 
as this ; but if it take only half a pint or a gill in the day, it is 
clear that it cannot be expected to live long on so much less than 
its natural quantity. It ought to take, it seems to me, under these 
circumstances, about two or three table spoonfuls of food every two 
or three hours, between morning and evening, and once or twice 
during the night, which would give it from eight to ten ounces 
in the day. The quantity must be regulated, however, by the 
condition of the infant, and particularly by the manner in which it 
takes the food, when offered. The child must never be forced to 
take more than it wants. The moment it seems to have had 
enough, the nurse should cease to offer any more. 

Having determined the quantity, the preparation of the food 
must be attended to. The milk and water ought always to be 
prepared by boiling for two or three minutes, stirring all the time, 
after which it is to be moderately sweetened with loaf, and not 
brown sugar. If this is found to disagree with the stomach, which 
is to be inferred when it is always rejected by vomiting, and when 
considerable quantities of undigested curd are found in the stools, 
the diet must be changed. Under these circumstances we may try 
thin arrow-root or barley water, containing only a sixth part of 
milk ; or cream and water, one part of the former to three, four, 
or five of the latter ; or we may endeavour to obtain asses' or 



TREATMENT. 193 

goats' milk, and use it diluted with an equal quantity of water in- 
stead of two-thirds. 

I would recommend in these cases a diet which I have found 
to agree better with children deprived entirely of the breast, 
than any other that I have ever directed. I have employed it 
now in a great many instances, and believe it to be the best sub- 
stitute for the natural aliment that I am acquainted with. It is 
made by dissolving a small quantity of prepared gelatine or Russian 
isinglass in water, to which is added milk, cream, and a little 
arrow-root, or any other farinaceous substance that may be pre- 
ferred. The mcde of preparation, and the proportions are as fol- 
lows : A scruple of gelatine (or a piece two inches square of the flat 
cake in which it is sold) is soaked for a short time in cold water, 
and then boiled in half a pint of water until it dissolves, — about 
ten or fifteen minutes. To this is added, with constant stirring, and 
just at the termination of the boiling, the milk and arrow-root, the 
latter being previously mixed into a paste with a little cold water. 
After the addition of the milk and arrow-root, and just before the 
removal from the fire, the cream is poured in, and a moderate 
quantity of loaf sugar added. The proportions of milk, cream, 
and arrow-root, must depend on the age and digestive power of the 
child. For a healthy infant within the month, I usually direct 
from three to four ounces of milk, half an ouflee to an ounce of 
cream, and a teaspoonful of arrow-root to a half pint of water. 
For older children, the quantity of milk and cream should be 
gradually increased to a half or two-thirds milk, and from one 
to two ounces of cream. I seldom increase the quantity of gelatine 
or arrow-root. 

I have given this food to a great many children for upwards of 
a year past, as well to those brought up entirely on hand, as those 
partly suckled, or weaned, and can truly state that they have 
thriven better upon it than upon anything that I have ever employed. 
In several cases it has agreed perfectly well with infants who could 
not without vomiting, diarrhoea, and colic, take plain milk and 
water, cream and water, any kind of farinaceous food prepared 
with water, chicken water, or in fact any other food that had been 
tried. In the cases of sick children, it ought sometimes to be 

17 



194 THRUSH. 

made even weaker for a while, than in the first proportions men- 
tioned above. 

No general treatment is required in the simple idiopathic form 
of the disease, beyond regulation of the diet, and the occasional 
use of warm baths. Local treatment will almost invariably suffice 
for the cure. 

In the grave form of the disease, it is necessary after regulating 
the diet, to employ remedies for the disordered condition of the 
alimentary canal. These should consist principally of alkalies, 
astringents, opiates, occasionally a dose of some laxative substance, 
nitrate of silver, and the external employment of baths, warm 
cataplasms to the abdomen, and sometimes of revulsives. 

The alkalies usually employed are soda, lime water, magnesia, 
chalk, and prepared crab's-eyes ; of these I prefer in most cases, 
the soda, lime water, chalk, or crab's-eyes, to be given in the 
manner which will be recommended in the article on entero- 
colitis. Dewees recommends very highly the following formula : 
R. — Magnes. alb. ust. gr. xii ; Tinct. thebaic, gtt. iii ; Sacch. 
alb. q. s. ; Aqua font. gi. — M. A teaspoonful to be given every 
two hours until the bowels are tranquil. He says of it that he has 
" long adopted it with entire success." In conjunction with the 
internal use of alkalies and astringents, I would recommend the 
practice pursued by M. Valleix, of employing opiate enemata, and 
warm poultices containing laudanum, applied upon the abdomen. 
The enemata should consist of one drop of laudanum in a table- 
spoonful of starch water, for young infants, to be used morning and 
evening. The poultices may be made of indian or flaxseed meal, 
placed between two pieces of soft gauze flannel, to be secured 
around the body by a band, and renewed from time to time. 

Purgative remedies are much used in this country in all cases 
of intestinal disorder. I believe them to be unnecessary, and 
generally injurious in thrush, except at the onset, and occasionally 
through the course of the disease, when we may suppose the 
bowels to contain accumulations of partially digested aliment, or 
highly irritating secretions. Under these circumstances, and only 
then, from half a teaspoonful to a teaspoonful of castor oil, or a 
teaspoonful of spiced syrup of rhubarb, containing half a drop of 



TREATMENT. 195 

laudanum, may be prescribed, and repeated in case the same con- 
dition of things should recur. Once the diarrhoea with green 
watery stools established, I believe all cathartics to be, as a rule, 
injurious. 

Opiates in moderate quantities, given in combination with al- 
kalies or astringents, or used by injection or externally, are of 
the greatest service at all stages of the grave form of the disease. 
When the diarrhoea is severe and obstinate, and particularly when 
the stools contain mucus or blood, or are attended with tenesmic 
straining, nitrate of silver given internally, and used by injection, 
may be resorted to with very probable benefit. The doses and 
modes of administration will be described under the head of entero- 
colitis. 

Some authors recommend the application of one or two leeches 
to the margin of the anus, or over the left iliac fossa. It seems to 
me that they can rarely be proper, and if so, only in vigorous, hearty 
children, and in cases presenting strongly marked inflammatory 
symptoms. When the symptoms indicate great exhaustion, or tend 
towards a state of collapse, resort must be had to stimulants, of 
which the best are weak brandy and water, or a mixture of equal 
parts of wine whey and arrow-root water. 

Local treatment. — The local treatment is important in all cases, 
but I am disposed to think that it is of much less consequence than 
the general treatment, and particularly attention to diet, and the 
other hygienic conditions of the patient. Topical remedies un- 
doubtedly have the effect, however, in many instances, of arresting 
the progress of the exudation, and hastening the resolution of the 
disease of the mouth ; but I have uniformly found in grave cases, 
that no remedies applied to the mouth, had any decided influence 
upon the abdominal disease, which is, after all, the cause of the 
fatal termination in the vast majority of cases. The local treat- 
ment ought therefore, it seems to me, to be regarded as adjuvant 
only to the general management of the disorder. 

In mild cases the most suitable local treatment, the one recom- 
mended by Underwood, Dewees, Eberle, and Trousseau and Del- 
pech, and that which I have generally employed, is the occasional 
application to the mouth of borax. It may be used mixed with an 



196 THRUSH. 

equal quantity of honey, and applied by means of a rag or pencil; 
or with an equal quantity or two parts of finely powdered white 
sugar, of which a pinch is to be put upon the tongue every two or 
three hours ; or in solution, in the proportion of a drachm to two 
ounces of water. The best mode probably is to mix it with honey. 
If this application fail to arrest the deposit of the exudation, we 
may resort to alum in powder or solution, or better still, to solu- 
tions of nitrate of silver, or careful cauterization with the solid 
nitrate. The alum may be used in the same manner as borax, or 
according to the following formula, recommended by M. Valleix. 
R. — Aluminis gr. xv ; Mel. rosse 3iiss ; Decoct. Hordei 3iijss. — M. 
In the use of the nitrate of silver, I should resort to a solution of 
eight or ten grains to the ounce of water ; Trousseau and Delpech 
however, employ one of thirty grains to the half ounce, or more 
frequently cauterize lightly the whole mucous surface with the 
solid caustic. 

Between the application of any of the above-mentioned remedies, 
the mouth of the infant ought to be occasionally moistened and 
cleansed with some of the mucilaginous solutions, as gum water, 
flaxseed tea, or that made from sassafras pith, slippery elm bark, 
or marsh-mallow root. 

Strict and careful attention must be constantly paid to the state 
of the skin around the anus, and upon the thighs and buttocks. 
These parts ought to be well cleansed, after each evacuation of 
urine or stool, by gentle pressure, and not by rubbing, with a fine 
sponge dipped into tepid milk and water, then dried with a soft 
napkin, in the same manner, and well anointed with simple cerate, 
or what I find better than anything else, Goulard's cerate. These 
precautions ought to be still more carefully observed if erythema 
has already made its appearance. 



CHAPTER II. 

DISEASES OF THE THROAT, 

ARTICLE I. 

SIMPLE OR ERYTHEMATOUS PHARYNGITIS. 

Definition; synonymes ; frequency : — Simple pharyngitis con- 
sists of an erythematous inflammation of the pharynx, tonsils, and 
soft palate, unaccompanied by ulceration, deposits of false mem- 
brane, or gangrene. It is not mentioned by Underwood. It is 
described under the title of cynanche tonsillaris by Dewees and 
Eberle, and of tonsillitis by Stewart and Condie. It is very fre- 
quent both as an idiopathic and secondary disease. I met with 
twenty-five idiopathic cases during January, February, and March, 
1847, in children from eight weeks to 5 years old. 

Causes. — It may occur at all ages, and is equally common in 
the two sexes. It is more frequently a secondary than an idiopa- 
thic affection. The diseases in the course of which it is most apt 
to occur are scarlet fever and measles, and next pneumonia and 
bronchitis. It is often an accompaniment of simple laryngitis. 
The idiopathic form is most common in this city in the late 
winter and early spring months. The twenty-five cases observed 
by myself, all occurred during January, February, and March, 
while I did not meet with a single case in the preceding No- 
vember or December. It is said to prevail sometimes in an epi- 
demic form. 

The exciting causes of the disease are not easily detected. In 
some instances, however, I have been convinced that exposure to 
cold has been the cause of the attack. 

Anatomical lesiojis. — In mild cases the alterations of texture 
observed during life, and in a few instances after death, the patient 

17* 



198 SIMPLE PHARYNGITIS. 

having perished of some other disease, consist of greater or less 
redness, swelling, softening, and a rough or granular and some- 
times cedematous condition of the mucous membrane covering the 
soft palate, tonsils, and pharynx. The uvula and tonsils are gene- 
rally tumefied, and the crypts of the latter filled with mucous or 
purulent fluid, of a yellowish colour. In one very severe case 
which proved fatal, MM. Rilliet and Barthez found the tonsils very 
red, soft, only slightly swelled, and infiltrated with pus; the pha- 
rynx was covered with a thick layer of bloody mucus ; the mucous 
membrane of the throat was of a dark red colour, thickened, and 
granular, but not softened. The sub-maxillary glands were of a 
grayish colour, enlarged and soft. 

Symptoms. — Simple pharyngitis of moderate severity, begins 
with restlessness, irritability, fever, slight cough, and in some in- 
stances, pain in the throat, which is complained of by older chil- 
dren, and betrayed in those who are very young, by the refusal to 
nurse or take food, because of the difficulty of swallowing. The 
face is generally flushed, sometimes very deeply so. Young chil- 
dren are often drowsy, but from irritability and fever refuse to 
sleep except on the lap. The fever is marked by acceleration of 
the pulse, which rises to 100, 110, or more in children over five 
years of age, and to 120, 130, or 140 in those under that age, and 
by unusual warmth or even heat of the skin. At the same time 
the respiration is generally more frequent than natural, but almost 
always regular ; in cases attended with high fever, I have counted 
the breathing at 42 and 50. Auscultation reveals pure vesicular 
murmur or slight sibilant rhonchus. The voice is clear, or, in 
rather severer cases, obscured and nasal, and in some instances, 
speaking is painful and difficult. Cough is a frequent symptom. 
It was present in 20 of the 25 cases observed by myself. In 6 of 
these it was harsh and croupal, so that the children seemed threat- 
ened with croup. The croupal sound seldom lasted over one night, 
after which the cough was merely hoarse, and gradually became 
loose towards the termination of the attack. In the remaining 
cases it was rare and dry in the beginning, and more frequent and 
looser as the disease progressed. Pain is a frequent, but far from 
constant symptom at the onset of the disease. It generally ex- 



SYMPTOMS. 199 

ists during deglutition. When present it is shown in infants, as 
stated, by their refusing the breast, or nursing only at long inter- 
vals, and with difficulty ; while in older children it is complained 
of. It is not, however, a constant symptom, as I have often seen 
children of one, two, and three years old, with severe angina pro- 
ductive of violent fever, who swallowed fluids and soft solids with- 
out a sign of pain. Of 22 cases in which the state of this symptom 
was particularly noticed by myself, it was present only in 7. 
Throughout the acute period of the disease there is generally con- 
siderable thirst ; the appetite is diminished or entirely suppressed ; 
the stools are usually natural, or there is slight constipation. 

The throat should always be examined when there is the least 
reason to suspect that an attack of sickness depends upon in- 
flammation of that part, and whenever a child has been suddenly 
seized with fever, particularly in cold weather, and there is nothing 
more evident by which to explain the illness. To examine this 
part well, the tongue must be strongly depressed with the handle 
of a spoon, which should be carried back to the base of the tongue. 
This may be done in the youngest infant. 

The appearances presented by the throat are as follows : — the 
soft palate, uvula, tonsils, and generally the pharynx also, are 
more or less reddened and swelled, and the mucous membrane 
commonly looks rough and granular. The fauces are often filled 
with frothy mucus, and in severe cases, coated all over with mucous 
or purulent secretions, which sometimes line the inflamed surfaces 
in such a way as to resemble false membranes. They are to be 
distinguished only by careful examination, and by removing a 
small portion on a pencil or sponge mop, in order to ascertain their 
real nature. I have seen the mild form of inflammation in a child 
ten days old, in one eight weeks, another three months, and a 
fourth nine months old. 

The sub-maxillary glands and neighbouring cellular tissue are 
sometimes swollen, in consequence of the extension of the inflam- 
mation to them. This is often evident to the eye, but is more cor- 
rectly judged of by the touch. At the same time the glands are 
usually somewhat painful to the touch. The amount of swelling is 



200 SIMPLE PHARYNGITIS. 

slight in very mild cases, or there may be none at all. In severer 
cases it is much more considerable. 

The breath is said to be often fetid. I have not met with this 
character in the simple disease. Eo:pectoratio?i is rarely present. 
I have never noticed it under six years of age. Slight nervous 
symptoms occur in nearly all the cases, consisting, as already 
stated, of restlessness and irritability in mild attacks, and of in- 
somnia or drowsiness, with starting and twitching, in those which 
are more severe. 

The fever generally occurs at first only in the after part of the 
day and during the night, often becoming intense at that time, with 
restlessness and starting, and subsiding or disappearing entirely to- 
wards morning, to recur again the next afternoon or evening. Chil- 
dren not unfrequently play about all the early part of the day, and 
are attacked with the symptoms just mentioned, as night comes 
on. The disease generally pursues this course for three or four 
days, and then passes away entirely, or, if it last beyond that time, 
the fever becomes continued and the attack runs on for seven, 
eight, or ten days. 

In grave cases of simple angina, the disease begins with vomit- 
ing, fever, and severe nervous symptoms, in the shape of excessive 
restlessness, or somnolence, and occasionally convulsions. The 
fever is violent, the pulse being very frequent and full, and the 
skin hot and flushed. The intense heat and flushing of the skin, 
which, in sanguine children, sometimes affects the greater part 
of the surface of the body, together with the activity of the circu- 
lation, not unfrequently make the onset of the disease resemble 
very closely that of scarlet fever. Four or five cases of this kind 
that have come under my notice, presented severe nervous symp- 
toms at the invasion. In a girl between two and three years old, 
they consisted of wildness and ecstatic expression of the face, and 
trembling uncertain movements of the limbs, which would pro- 
bably have terminated in convulsions, but for the timely interposi- 
tion of a warm bath. In the three others, general convulsions 
occurred. Two of the subjects in which convulsions took place, 
were between five and six years old, and one between three and 
four. In two the convulsions occurred at the onset, and in three 



SYMPTOMS DIAGNOSIS. 201 

on the second day. The convulsive movements lasted from ten to 
twenty minutes, and were followed by somnolence for a few hours 
in two, and by stupor for a day in the third. It should be stated, 
however, that two of these subjects were predisposed by constitu- 
tion and temperament to spasmodic attacks, as one had had a fit 
previously from a similar cause, and the other two from difficult 
dentition. The third had never suffered from any symptoms of 
the kind, and did not appear predisposed to them. 

The tongue is generally dry and coated with a thick whitish 
fur in grave cases ; the respiration is quick, loud, and nasal ; and 
the voice guttural or nasal, and difficult. There is usually extreme 
thirst, and not unfrequently delirium. The throat is commonly vio- 
lently inflamed, of a deep red colour, and coated over with mucous or 
purulent secretions. The sub-maxillary regions are often swelled, 
and the deglutition sometimes, though not always, difficult. When 
the disease proves fatal, the different symptoms soon reach their 
height, and death may occur in two or three days. I have never, 
however, known simple pharyngitis to terminate fatally. The 
duration of the grave cases is variable. In the five that I have 
met with, it was between three and eight days. 

Secondary pharyngitis, which, as has been stated, is a very 
frequent disease, will be treated of in the articles on the various 
diseases, in the course of which it occurs. 

Diagnosis. — The diagnosis of simple pharyngitis is not always 
without difficulty, as there are no local symptoms in two-thirds of 
the cases at the invasion, nor in some instances at any period of 
the attack. The physician and attendants, therefore, are often 
deceived as to the real cause of the violent fever which has so 
suddenly made its appearance, and are disposed to refer it to any 
but the true one. 

It has happened to me several times in cases of children at- 
tacked with simple angina, to suspect pneumonia from the sudden 
occurrence of fever, rapid respiration, slight dry cough, and the 
absence of pain in the throat, difficulty of deglutition, or other 
symptoms to call my attention to the real seat of disease. The 
diagnosis is to be corrected only by the absence of the physical 
signs of pneumonia, and the consequent necessity of finding some 
otiier cause of the sickness. Angina may be mistaken also for 



202 SIMPLE PHARYNGITIS. 

indigestion, which is one of the most frequent causes of sudden 
fever in childhood, and is accompanied like severe angina by 
vomiting. The distinction between the two is to be made by 
careful inquiry as to the history of the attack, by examination of 
the matters ejected from the stomach, and by inspection of the 
throat. Severe cases, particularly when ushered in* by convul- 
sions, may be mistaken for disorder of the nervous system depen- 
dent upon dentition. The only method of ascertaining the truth is 
again the inspection of the throat. Cases of this kind might also 
be mistaken for the beginning of scarlet fever. Time only, and 
the development or absence of the symptoms peculiar to the latter 
disease, could enable us to determine the diagnosis. 

The diagnosis between simple and pseudo-membranous pharyn- 
gitis will be given under the head of the latter disease. 

Prognosis. — Simple pharyngitis of moderate severity is very 
rarely, if ever, a fatal disease. Severe or grave erythematous 
pharyngitis, on the contrary, is often a dangerous malady. The 
five cases that have come under my care, however, all recovered. 
The unfavourable symptoms in such cases are : very violent fever, 
greatly altered physiognomy, difficult respiration, choked and gut- 
tural voice, excessive jactitation, delirium, convulsions, and coma. 

Treatment. — Mild cases of simple angina need but little treat- 
ment. The child ought to be confined to a warm room in all 
cases, and kept in bed, or on the lap, if it have fever. The 
diet must be restricted to milk preparations and bread so long 
as the fever continues. The therapeutical part of the treatment 
may consist in the use of some mild evacuant, as one or two tea- 
spoonsful of castor oil, half a teaspoonful or a teaspoonful of mag- 
nesia, a small quantity of syrup of rhubarb, or what is all-suffi- 
cient in many cases, a simple enema. At the same time we may 
give, if the frequency of pulse, heat of skin, and restlessness 
be considerable, a few doses of sweet spirits of nitre, or spiritus 
Mindereri, alone, or combined with from one to four drops of an- 
timonial wine, according to the age. A warm bath, if the child is 
not afraid of it, is an admirable remedy when there is much ex- 
citement of the circulation; or a foot bath, containing salt or mus- 
tard may be used. Frictions over the throat and neck are often 



TREATMENT. 203 

very advantageous ; they may be made with hartshorn and sweet 
oil, with or without the addition of laudanum, or a small quantity 
of spirits of turpentine may be applied upon the skin, so as to 
produce slight counter-irritation. When there is much pain and 
difficulty of deglutition, the case is best treated by the use of nitrate 
of silver in solution (5 or 10 grains to the ounce), or of powdered 
alum, applied by means of a large throat-brush. 

In the severe form of the disease the treatment must be much 
more active than in mild cases. When the fever is very high, 
and threatening nervous symptoms are present, the most speedy 
means of controlling them is a warm bath, lasting fifteen or twenty 
minutes. If the effects of this should be but slight or transitory, 
bloodletting must be resorted to. In a very young child the proper 
means of taking blood is by the application of a few leeches behind 
the angles of the jaw ; in those who are older, on the contrary, a 
venesection of from two to four ounces is much better, because at 
that age, the dread of leeches is so great, that the fright and con- 
sequent resistance on the part of the child, is always a serious, 
and in some cases an insuperable objection to their use. Some 
evacuant dose should be given early in the attack ; it may consist 
of castor oil, magnesia, epsom salts dissolved in lemonade, fluid 
extract of senna, or infusion of senna and manna. The quan- 
tity must be sufficient to produce several copious stools, and 
should it fail to operate in three or four hours, and the fever con- 
tinue, it is always well to assist it by means of a purgative enema. 
Two hours after the exhibition of the cathartic, it will be proper to 
resort to small doses of antimonial wine or tartar emetic solution, 
with nitre, repeated every hour and a half or two hours, in the 
manner recommended in the article on pneumonia. If the secre- 
tions into the fauces be very abundant and tenacious, so as to 
impede respiration, the best means of getting rid of them is 
by an emetic of ipecacuanha, hive syrup, or antimonial wine. 
If they collect again, the throat ought to be cleansed from time 
to time with a small sponge-mop. The inflamed surfaces 
should be touched two or three times a day with a solution 
of nitrate of silver (from five to ten grains to the ounce). My 
father has been in the habit of employing with much benefit in the 



204 PSEUDO-MEMBRANOUS PHARYNGITIS. 

severe angina of children, whether idiopathic or secondary, a wash 
made according to the following formula : R. — Cupri sulphat., 
Quinise sulphat., aa gr. vi ; Aquce destillata3 3i. — M. This is 
applied in the same way as the lunar caustic solution, and I have 
frequently seen it produce most excellent effects. 

The five grave cases observed by myself recovered under very 
simple treatment. This consisted in the use of the warm bath ; 
doses of castor oil to move the bowels freely on the first day, and 
of syrup of rhubarb or enemata afterwards to keep them soluble ; 
of doses of antimonial wine and nitre every two hours in such 
quantity as to avoid sickness ; of mustard pediluvia ; stimulating 
frictions to the outside of the throat ; applications of lunar caustic 
solution to the throat internally, three or four times a day ; and of 
rigid diet. In one case the warm bath was used three times in a 
single day, because of the extreme restlessness and heat of skin, 
and was productive each time of great benefit. 



ARTICLE II. 

PSEUDO-MEMBRANOUS PHARYNGITIS. 

Definition ; synonymes ; frequency. — Pseudo-membranous pha- 
ryngitis consists in inflammation of the pharynx, accompanied by 
an exudation of false membrane upon the mucous tissue. 

It is the disease called by older writers angina maligna or gan- 
grenosa, cynanche maligna, etc. In this country it is popularly 
known by the name of putrid sore throat. It is designated angina 
suffocativa, or sore-throat distemper, by Dr. Sam. Bard, of New 
York, whose paper ( Trans. Am. Philos. Soc. vol. i), is the best 
of the early productions upon the subject. It is the diphtkerite of 
M. Bretonneau. Underwood and Dewees make no mention of it. 
Eberle, in his chapter on tonsillitis, confounds it with simple an- 
gina ; but it is evident that he had met with the disease from the 
fact of his remarking that flakes of coagulable lymph, resembling 
superficial sloughs, sometimes adhere to the inflamed tonsils, and 
that the inflammation passes down into the larynx in some in- 



CAUSES. 205 

stances. Dr. Condie describes it under the title of pseudo-mem- 
branous or diphtheritic inflammation of the throat. 

It is difficult to arrive at a correct appreciation as to its fre- 
quency. It may be stated, however, that it is rare as a sporadic 
affection, while it sometimes prevails to a considerable extent as an 
epidemic disease. 

Causes. — It occurs both in the sporadic and epidemic forms. 
Guersent states that it is to be met with in Paris at all seasons, and 
under all temperatures. It is strongly disposed, however, to as- 
sume the epidemic form, and may then prevail over districts of 
greater or less extent. 

It has been thought by many to be propagated by direct con- 
tagion. Such is the clearly expressed opinion of MM. Trousseau 
(Diet, de Med. t. x, p. 393), Valleix {Guide du Med. Prat. t. iv, 
p. 350), and Guersent (Diet, de Med. t. hi, p. 128-129). M. 
Bretonneau ( Traite de la Diphtherite), is strongly disposed to the 
same opinion, without, however, positively adopting it. Rilliet 
and Barthez are fully convinced that the disease is contagious. I 
have met with but one instance in my own practice which seemed 
to show that it possessed this character. This was the case of a 
boy two years and a half old, who was attacked with the disease, 
while his sister, an older child, was already dangerously ill with it. 
On the other hand, I have met with four cases in families in which 
several other children were allowed free access to the sick room, 
none of whom were attacked. 

Dr. Geddings, of South Carolina, in a valuable monograph on 
" pseudo-membranous inflammation of the throat," (Am. Jour. 
Med. Sci. vol. xxiv, p. 82,) says that diphtheritis depends on an 
epidemic constitution of the atmosphere, but that " under particular 
circumstances, as when many persons are crowded together, when 
ventilation is imperfect and cleanliness is neglected, there can be 
no question of the generation of a contagious influence, capable 
of transmitting the disease from one person to another." Dr. Bard 
(Loc. cit.) states that the disease was of an " infectious nature," 
and that the infection depended not so " much on any generally 
prevailing disposition of the air, as upon effluvia received from the 
breath of infected persons. This will account why the disorder 

18 



206 PSEUDO-MEMBRANOUS PHARYNGITIS. 

should go through a whole family, and not affect the next-door 
neighbour ; and hence we learn a very useful lesson, namely, to 
remove all the young children in a family, as soon as any one is 
taken with the disease ; by which caution, I am convinced, many 
lives have been, and may again be preserved." It is most fre- 
quent between the ages of two and eight years, and more common 
in boys than girls. It is said that children of feeble constitution, 
and those subjected to bad hygienic conditions or debilitated by 
severe illness, are particularly exposed to it, especially in the 
sporadic form. 

The secondary form occurs most frequently as a complication 
first of scarlet fever, and then of typhoid fever and measles. 

Anatomical lesions. — The false membranes covering the pha- 
rynx, soft palate, and tonsils, are of a yellowish-white or grayish 
colour, of rather tough consistence, and of variable thickness. 
They may consist of one or several layers, and adhere with mo- 
derate tenacity to the mucous membrane. They are sometimes 
ash-coloured, and being softened by the pharyngeal secretions and 
tinged with blood, which is often exuded from the mucous tissue 
in diphtheritic inflammation, have under these circumstances, fre- 
quently been mistaken for sloughs of the mucous membrane, thus 
giving rise to the old titles of angina gangrenosa, putrid sore throat, 
etc. The mucous membrane is generally injected and red, and 
often presents ecchymosed spots. In some cases it is softened and 
roughened, or even deeply ulcerated, so that the false membrane 
may rest upon the muscular tissue of the pharynx. The ulcera- 
tions, though rare in the primary, are not uncommon in the se- 
condary form. The sub-maxillary glands are almost always en- 
larged, but very seldom in a state of suppuration. 

In the secondary form of the disease, the mucous membrane is 
more violently inflamed. It is of a deep red colour, rough, and 
very much thickened and softened. The tonsils are large and soft, 
uneven, and often infiltrated with pus. It is not unusual in this 
form, to meet with ulcerations of the mucous membrane. False 
membranes are almost always present; generally on different por- 
tions of the fauces, and more rarely over their whole extent. They 
are generally rather soft and thin, of a whitish, grayish, or yellow 
colour, dispersed in fragments and easily torn. The inflamed 



SYMPTOMS DURATION. 207 

parts are usually bathed in purulent fluid. The sub-maxillary 
glands are large, red, and soft. 

Symptoms; duration. — The disease begins usually, but not in 
all cases, with slight fever. The strength and appetite are not 
much disturbed at first, but, as the attack progresses, the former 
is diminished and the latter suppressed ; the thirst remains natural. 
There is at the same time, in some, but not all cases, pain in the 
throat, which may or may not be accompanied by difficulty of 
deglutition. Both these symptoms, however, are not unfrequently 
absent for several days. In a fatal case at three years of age 
that came under my notice, there were neither complaints of pain, 
nor difficulty of swallowing, so that the parents had not the least 
suspicion of the throat being the seat of disease, though I found it 
violently inflamed, and covered with deposits of thick false mem- 
brane in points. If the fauces be examined on the first day of 
fever, the exudation may often be found even at that time, though 
it is sometimes not formed before the second day. The fauces 
generally present slight swelling and redness before the appear- 
ance of the false membrane, which almost always shows itself first 
on one of the tonsils only, in the form of whitish or opaline spots, 
like coagulated mucus, which soon run together and extend over 
the whole gland, and then to the soft palate and pharynx, though 
it sometimes remains limited to the tonsils and soft palate. A little 
later in the attack the plastic deposit exists in the form of layers of 
greater or less extent ; it has lost its transparence, become firmer 
in consistence, thicker, and changed from a white to a yellowish- 
white or lardaceous and sometimes grayish colour. The sub- 
maxillary glands are almost always enlarged and painful to the 
touch about three or four days after the appearance of the pseudo- 
membrane. The breath is offensive but not fetid. When this 
form of the disease, which is the one most frequently observed, is 
left to pursue its natural course, the pseudo-membrane becomes 
thinner, assumes a grayish tint, and falls off about the sixth or 
seventh day. When on the contrary, topical remedies are applied 
to the throat, the membrane is often detached after one, two or 
three days, but is reproduced several times before the conclusion 
of the case. 



208 PSEUDO- MEMBRANOUS PHARYNGITIS. 

In another and more violent form of the disease, the pseudo- 
membrane, about the time that it begins to be detached, assumes 
a grayish or blackish colour, and hangs in shreds from the sur- 
faces to which it was attached. The fauces, under these circum- 
stances, present a gangrenous aspect, the mucous membrane having 
an appearance as though it were falling off in sloughs ; the breath 
is extremely fetid, and there is more or less abundant salivation, 
or in some cases an expuition of sanguinolent fluid. There can be 
no doubt that it was from misconception of such cases as these, 
that the titles of gangrenous and putrid sore throat arose. 

As the exudation disappears from the pharynx, the swelling of 
the parts affected gradually subsides. The mucous membrane, 
from which the plastic deposit has just fallen, is more or less in- 
jected and red ; the tonsils and soft palate are sometimes found to 
be reduced below their natural size. 

The general symptoms of pseudo-membranous pharyngitis are 
often slight compared with the dangerous character of the local affec- 
tion. There is generally but little fever, attended with very mode- 
rate heat of skin during the first few days, after which it often in- 
creases and the skin becomes hot and dry, though, not unfre- 
quently, these symptoms are but slightly marked throughout the 
attack. When, on the contrary, the fever is more violent during 
the first day or two, it usually soon subsides, though in some in- 
stances, it remains intense, and in one of the cases observed by 
myself, the pulse was full and frequent, and the heat very great 
after the second day. The principal symptoms connected with 
the digestive organs are loss of appetite and moderate thirst. 
These are not generally present in the beginning, but make their 
appearance a few days after the invasion. Vomiting is rare and 
the stools are normal. 

The voice is commonly obscured and nasal, but not hoarse nor 
whispering unless the disease extends into the larynx, in which 
case the symptoms will be those of true croup, already described. 
Cough sometimes exists, but it usually resembles in sound that 
produced by the action of hawking rather than a common cough, 
and is altogether different from the tone of the cough of laryngitis. 



SYMPTOMS DIAGNOSIS PROGNOSIS. 209 

The only other symptoms which require mention are the pre- 
sence of more or less marked languor, depression, and loss of 
strength. 

The pharyngeal inflammation and exudation frequently exhibit 
a strong tendency to extend to the larynx, and it is this which 
often causes the fatal termination. At other times they spread to 
the nasal passages, and thereby add greatly to the danger of the 
case. Again, the false membranes are formed in some rare cases 
upon different portions of the general integument, particularly 
upon the alse nasi, behind the ears, about the anus, vulva and 
nipples, and upon a blistered or any excoriated surface. 

The duration of the disease, independent of complications, is 
usually about seven, eight, or nine days. If it extend into the 
air-passages very soon after the invasion, it may cause death within 
a few days. In most of the cases, however, the larynx does not 
become implicated under five or six days. In one of my cases, 
death occurred on the sixth day, and in another on the fifth ; in 
both from the extension of the disease into the larynx. Bard says 
that of seven deaths, five occurred before the fifth, and two about 
the eighth day. 

Diagnosis. — The diagnosis of pseudo-membranous pharyngitis 
can present no difficulties, if the throat is but examined at an early 
period. When there is neither pain in the throat, nor difficulty of 
deglutition, the practitioner might possibly be deceived as to the ^ 
nature of the illness. The swelling of the lymphatic glands under 
the jaw, the embarrassed movements of the neck, and the absence 
of other causes to explain the sickness of the child, ought to lead 
to an inspection of the fauces, which would, in an instant, reveal 
the true character of the attack. 

The distinction between simple and pseudo-membranous angina 
can only be made out during the existence of the pharyngeal exu- 
dation, as the symptoms of the latter disease are nearly identical 
with those of the former, before the deposit and after the fall of 
the false membranes. 

Prognosis. — If the disease remain limited to the pharynx, it is 
almost always a very curable affection. When, on the contrary, 
it extends to the nasal passages, the prognosis is more unfavoura- 

18* 



210 PSEUDO-MEMBRANOUS PHARYNGITIS. 

ble, and when the larynx becomes implicated, the prognosis is 
exceedingly grave ; if the disposition to the production of false 
membrane spread to the skin, rectum or vulva, the prognosis is 
also very grave, and death generally occurs in a state of profound 
adynamia. 

Treatment. — The treatment may be usefully considered under 
two heads, the local and general. It is now commonly conceded 
that the former is more important than the latter. The great ob- 
ject to be held in view, is to prevent if possible, the extension of 
the pseudo-membrane from the fauces into the larynx and nasal 
passages, which is generally supposed to be gained more certainly 
by the use of local remedies than by general treatment. 

Local treatment. — The most important of the local remedies 
are the nitrate of silver and muriatic acid. These are the two 
remedies most highly recommended by MM. Bretonneau, Valleix, 
Grisolle, and Rilliet and Barthez. Dr. Geddings {Joe. cit.) speaks 
very highly of the success of the caustic treatment in his hands, 
in the epidemic which occurred in Charleston during 1837 and 
1838. He employed either the nitrate of silver or muriatic acid. 

The nitrate of silver is employed in solution or substance. The 
latter form is objected to by many on account of the risk of its 
slipping from the port-caustic into the pharynx, and thence passing 
into the stomach. The solution is therefore generally preferred. 
Bretonneau employs it in the proportion of half an ounce of the 
nitrate to an ounce and a half of water. The solution ought in 
fact in violent cases, to be saturated ; while in those which are less 
severe, one of twenty grains to the ounce would be sufficiently 
strong. It may be applied either by means of a piece of sponge 
fastened upon a proper handle, or what I prefer, a camel's hair 
pencil, nearly as large as the end of the little finger. The appli- 
cation should be made once, twice, or even three times in the 
course of twenty-four hours. Dr. Geddings recommends, when it 
is desirable to use the solid nitrate, to reduce it to powder, and to 
roll the sponge probang previously moistened with mucilage of 
gum arabic and squeezed, in the powder until a sufficient quantity 
adheres, and to apply it thus prepared to the diseased parts. 



TREATMENT. 211 

The muriatic acid is employed by M. Bretonneau either pure 
or mixed with honey. When the limits of the pseudo-membrane 
can be seen in the pharynx, he uses the concentrated acid, and 
carrying the sponge, after it has been dipped into the acid, and 
squeezed so as to be merely moistened, rapidly into the pharynx, he 
cauterizes lightly and withdraws it. When, on the contrary, the 
limits of the membrane cannot be seen, he dilutes the acid with 
an equal quantity of honey, and leaving more of it on the sponge 
than in the previous case, he recommends that the latter be passed 
down over the glottis, and then pressed against the base of the 
tongue, by raising strongly the handle to which it is tied, in order 
to express a few drops upon the mucous lining of the larynx. The 
cauterization is to be performed once or twice a day, according to 
the necessity of the case. For children under ten years of age, 
the sponge ought to be about half as large as a pigeon's egg. 
The sponge is to be fastened to a piece of flexible whalebone, by 
making a crucial incision into it, introducing into this the end of 
the whalebone, and securing it with good sealing-wax, which is 
not acted upon by the acid as any ligature would be. When about 
to be used the-whalebone is warmed and curved into such a shape 
as will allow it to pass into the pharynx without touching the roof 
of the mouth. M. Valleix proposes that the sponge should be 
fastened to the whalebone with waxed thread, and this to be covered 
with sealing-wax, to preserve it from the action of the acid. This 
would certainly be safer than the mere wax itself. 

Applications of powdered alum, and chloride of lime are recom- 
mended by writers of high authority. It seems to me that in 
slight cases, in which the disease shows but little disposition to 
extend, such applications may answer very well, but when the 
attack is threatening, and especially when the exudation is spread- 
ing, we should neglect all minor remedies of this kind, and 
resort at once either to lunar caustic or muriatic acid. If, 
however, the powders are employed, they may be applied by 
means of a throat-brush, or by causing a sufficient quantity to 
adhere to the end of the forefinger of the right hand, and convey- 
ing it upon this to the diseased surfaces. 

There is no real difficulty in making use of any of these appli- 



212 PSEUDO-MEMBRANOUS PHARYNGITIS. 

cations, if the children be properly managed. One or two assist- 
ants must hold the patient in such a way that the head shall be 
thrown backwards, and the hands and feet secured. The physician 
must depress the tongue with the handle of a spoon held in the 
left hand, while he holds in the right the pencil or sponge-mop. 
If the child refuses to open the mouth, it can generally be made to 
do so by holding the nose in order to force it to breathe through 
the mouth. If this fail, all that is necessary is to press the handle 
of the spoon against the teeth, when the patient will soon become 
too much fatigued to offer further resistance. 

General treatment. — Bloodletting may be resorted to with ad- 
vantage very early in the attack, if the child is vigorous and strong, 
the fever violent, and if there are no signs of prostration. When, 
on the contrary, the case is not seen within the first two or three 
days, depletion can seldom be resorted to with safety. By some 
it is proscribed entirely in the treatment of the disease. Thus, 
M. Valleix (Loc. cit n t. iv, p. 369,) says: "I will merely state 
that there is not a single case on record in which the disease 
was evidently arrested by antiphlogistic treatment, however en- 
ergetic it may have been." I believe, however, that I once 
saw the disease arrested by depletion. During the last week of 
October 1845, my father and myself were in attendance upon a 
girl five years of age, labouring under a most violent attack of the 
disease, which had extended into the larynx, and for several days 
exposed her life to the most imminent hazard. During the ex- 
tremity of her illness, her brother, a fine hearty boy two years 
and a half old, was taken sick in the evening of one day with 
considerable fever. On the following day, my father found the 
fauces very much inflamed, while at the same time there were 
patches of pseudo-membrane on each tonsil, and high febrile re- 
action. The boy was bled at once to four ounces. Four grains of 
calomel were given, and a few hours afterwards a dose of purga- 
tive medicine. The throat was touched with a solution of nitrate 
of silver, of ten grains to the ounce. The exudation was arrested 
at this point, though the fever continued for two days longer. It 
may be said that the nitrate of silver arrested the disease, but the 
solution was not a caustic one, and therefore hardly likely, it 



TREATMENT. 213 

seems to me, to have produced, by itself, so powerful an effect. I 
am disposed to believe from my own experience in this and other 
cases, that when resorted to early, and in vigorous subjects, it is 
a highly important and powerful remedy. I have employed it, on 
the contrary, later in the disease, without any good effects, and 
should, under such circumstances, depend rather on the local 
treatment, and the employment of mercurials. 

Mercury. — The preparations of mercury are undoubtedly those 
which are most powerful in causing the dissolution and absorption 
of the pseudo-membrane. But as Rilliet and Barthez remark, so 
long as the disease remains confined to the pharynx, there is but 
little danger attendant upon it, and it would be unnecessary, there- 
fore, to resort to so powerful an agent as mercury in such cases. 
We can ascertain with some degree of certainty whether the in- 
flammation is likely to extend into the larynx or not, by learning 
whether the disease be sporadic or epidemic, and if epidemic, 
whether it has shown a disposition to pass down into the air-pas- 
sages. If it be a sporadic case, or if the epidemic has not in 
general attacked the larynx, we may rely upon the local treatment, 
and bloodletting as advised above. If, on the contrary, the dis- 
ease be epidemic, and has shown a disposition to propagation into 
the larynx, the case should be treated with mercury, as this remedy 
has seemed to exert a more powerful influence in arresting the 
formation of the deposit than any that has been resorted to. The 
preparation generally made use of is calomel, which may be given 
in doses of from one to 4hree grains every two hours, until the 
disease appears to yield, or until some of the effects of the remedy 
on the constitution are visible. It is better in general to combine 
a small portion of opium with it, in order to prevent too early an 
action upon the bowels. 

Emetics. — Purgatives. — Emetics are useful when the exudation 
shows a disposition to extend to the larynx, or when there 
is much difficulty of breathing from tumefaction of the fauces, 
or from accumulations of the pseudo-membranous deposits. I 
would recommend under these circumstances the use of alum in 
the manner proposed in the article on pseudo-membranous laryn- 
gitis. If this be not employed, ipecacuanha or tartar emetic 



214 PSEUDO-MEMBRANOUS PHARYNGITIS. 

ought to be resorted to. The emetic may be repeated in six or 
twelve hours, if the same indication should continue or recur. 
A purgative dose is useful at the commencement of the disease as 
an antiphlogistic and evacuant. After that period, only laxatives 
need to be employed in order to keep the bowels soluble. 

Tonics and stimulants are to be resorted to only in the gan- 
grenous form of the disease, or towards the termination of the 
ordinary form, if the patient become weak and prostrated. In the 
gangrenous form the tonic treatment should be combined with the 
local treatment already described. Under these circumstances, 
the diet ought to consist of nutritious milk preparations, and of 
light broths, while wine and brandy in the form of whey, or milk 
punch, may be given in connexion with quinine, or some of the pre- 
parations of bark. 



CHAPTER III. 

DISEASES OF THE STOMACH AND INTESTINES. 
GENERAL REMARKS. 

The diseases of the digestive tube are involved in so much ob- 
scurity in consequence of the various forms in which they present 
themselves, and of the different opinions held by authors as to their 
nature, that I find myself greatly perplexed as to what may be the 
most proper manner in which to treat of them. After careful 
consideration, however, I have resolved to divide them into two 
classes, one of which will include all that seem to depend on simple 
functional derangement, independent of any anatomical alteration, 
cognizable by our senses ; and the other those which depend on 
evident inflammation or its consequences. It seems to me that 
this division is shown to be correct, by the following considerations : 

1. I believe that I have often met with cases of derangement 
of the digestive tube which could not be explained as to their 
causes, symptoms, course, and mode of recovery, on the supposi- 
tion of inflammation or other appreciable anatomical alteration. 

2. There are on record a considerable number of cases of greater 
or less derangement of the functional expression of these organs, in 
which the most careful examination after death could detect no 
alteration in the tissues to explain the symptoms. Such are the 
cases referred to by Billard, who says (Mat. des Enfa?is, p. 392) : 
" Many childi*en at the breast have diarrhoea without enteritis ; 
they lose colour, become etiolated, fall into a state of marasmus, 
but at the autopsy not a trace of inflammation of the intestines is 
found." Berton (Mai. des Enfants, 2me ed. p. 574) states that 
of 57 cases of gastro-intestinal disease observed by himself, there 
were 4 in which not. a trace of inflammation nor any appreciable 



216 DISEASES OF STOMACH AND INTESTINES. 

lesion of the digestive tube could be found. Rilliet and Barthez (t. i, 
p. 491,) remark that in about every twelve children affected with 
more or less abundant diarrhoea, in whom we might expect to find 
colitis, there will be one in whom the gastro-intestinal tube will be 
found in a state of perfect integrity. They add that this conclusion 
is deduced from a comparison of nearly three hundred autopsies. 
3. It is the opinion of several competent observers that such a 
division of the diseases of the digestive tube ought to be made. 
Billard treats of stomachal and intestinal indigestion, which, he 
says, may exist independent of inflammation. Barrier ( Trait. Prat, 
des Mai. de VEnfance,) is of opinion that it is indispensable to dis- 
tinguish certain lesions of secretion, which he describes under the 
title of diacrises (a word first employed by M. Gendrin,) from the 
inflammations of the gastro-intestinal tube. He asserts (t. iv, p. 
19,) that gastro-enteritis, gastritis, and enteritis, rarely constitute 
in children from one to fifteen years of age, complete and essential 
morbid conditions, conditions, that is to say, governed in their 
manifestation, course, duration, termination and treatment by the 
same laws, which preside over other essentially inflammatory 
diseases. In proof of this he states that in 122 cases of disease 
of the abdomen observed by himself, there were 54 of diarrhoea, 
10 only of inflammatory or catarrhal gastro-intestinal disease, 2 of 
verminous affection, and one of ulceration of the duodenum. Of 
these 67 cases, he says that five sixths at least of the attacks of 
diarrhoea ought to be classed amongst the diacrises or lesions of 
secretion. After describing the alterations which occur in the 
follicular diacrisis, he says (loc. cit. p. 33) : " These alterations 
are evidently not of an inflammatory nature, and will not justify 
us in giving to the disease the title of gastro-enteritis, or colitis, as 
has been done by most of the later writers, and particularly Billard, 
who attributed them to follicular gastritis or enteritis." M. Barrier 
therefore describes, first, the inflammatory affections of the diges- 
tive tube, under the usual title of gastro-intestinal inflammation ; 
and then the diacrises or lesions of secretion of the gastro-intestinal 
mucous membrane. Of the latter class he makes five divisions : 1 , 
follicular or mucous diacrisis; 2, acescent diacrisis, 3, serous 
diacrisis ; 4, ventose diacrisis ; 5, verminous diacrisis. M. Bouchut 



GENERAL REMARKS. 217 

(Man. Prat, des Mai. des Nouv-Nes,) divides the diarrhoeas of 
children into catarrhal or spasmodic, and inflammatory diarrhoea 
or entero-colitis. The former disease he believes to depend on a 
functional lesion with hyper-secretion of the intestinal mucous 
membrane, the anatomical cause of which escapes our search. 
It is independent, he says, of any appreciable alteration of the di- 
gestive tube. 

I think it must be admitted from the facts and opinions just 
stated that there are two distinct morbid conditions of the digestive 
tube ; one, in which thefe are no evident anatomical lesions, and 
another which depends upon inflammation and its results. To the 
first of these conditions I will apply, when it affects the stomach, 
the term indigestion ; and when it affects the intestines, that of 
simple diarrhoea. To the second class I shall apply the usual 
terms, gastritis, enteritis, and colitis. I would remark, however, 
that it seems to me most probable that these two states are often 
merely different degrees of disease", and that simple functional 
derangement will very often become inflammation, if it continue 
for any length of time. The follicular or mucous diacrisis of MM. 
Gendrin and Barrier probably depends at first upon functional dis- 
order of the secretory apparatus of the digestive tube, which fre- 
quently passes into inflammation and its consequences. 

Before beginning the history of the diseases of the stomach and 
bowels, I would call the attention of the reader to the well-esta- 
blished fact that it is much more common in children to meet with 
affections of these two portions of the alimentary canal occurring 
simultaneously, than with affections of either alone. Of 150 cases 
of inflammation of the infra-diaphragmatic portion of the digestive 
tube, carefully collected by Billard, there were 90 of gastroente- 
ritis, 50 of enteritis without gastritis, and only 10 of gastritis with- 
out enteritis. Of 57 cases of gastro-intestinal affections observed 
by M. Berton (loc. cit. p. 574), there were only 4 of gastritis alone, 
whilst there were 27 of gastritis complicated with some intestinal 
lesion, 4 of enteritis, 11 of entero-colitis, and 4 of colitis. In 3 
there was merely slight development of the isolated follicles, and 
in the remaining 4 not a trace of inflammation nor any other 
lesion. Rilliet and Barthez state that they have met with 61 cases 

19 






218 INDIGESTION. 

attended with some lesion of the stomach, in only 15 of which 
was that organ alone affected, whilst in the remaining 46 there 
was either duodenitis, enteritis, colitis, follicular enteritis or colitis, 
or lastly, softening of the mucous membrane. The authors of the 
Bibliotheque du Medecin Praticien state (t. v, p. 573,) "that it is 
rare to find any serious alteration of one of its (gastro-intestinal 
canal) portions, without the others participating to a greater or less 
extent." M. Bouchut (loc. cit.) appears to think that diseases 
of the stomach never occur in children as a separate lesion, at 
least he asserts this of softening of that organ (p. 231), and treats 
of the other alterations of its mucous tissue only under the head 
of entero-colitis. 



SECTION I. 

FUNCTIONAL DISEASES OF THE STOMACH AND INTESTINES. 

ARTICLE I. 

INDIGESTION. 

Definition ; frequency ; forms. — By the term indigestion, I 
mean that condition of the stomach in which its function of diges- 
tion is disturbed or suspended, independent of inflammation or other 
disease of the organ, appreciable by our senses. It is a very fre- 
quent affection during the whole period of childhood, and is one of 
great importance on this account, and from the fact of its laying 
the constitution open by the debility and cachexia which it pro- 
duces, to various secondary affections. ]ji my description of the 
disease, I shall distinguish between the forms which occur during 
infancy, and after the completion of the first dentition. 

Causes. — The principal causes of indigestion in infants are an 
unhealthy state of the milk of the nurse, the use of artificial diet, 
and lastly, an impaired condition of the digestive function, which 
disables the stomach from digesting even the most healthful ali- 
ment. 



CAUSES. 219 

The milk of the nurse may be too old for the child, for it has 
been found that a breast several months old, sometimes, though 
not always, disagrees with a young infant, in consequence no doubt 
of the milk being thicker and richer at that time than immediately 
after parturition. The breast-glands may continue to secrete colos- 
trum for weeks or even months after parturition, and when this is 
the case the child is almost sure to suffer from indigestion and 
diarrhoea. The milk may be unwholesome because the nurse is 
in bad health, or because her diet is not properly regulated. That 
the diet of the nurse affects her milk, I have no doubt, though this 
has been denied by some persons. 

I have known several children to suffer from indigestion, at- 
tended with vomiting, acid secretions, colic, and diarrhoea, in con- 
sequence of the nurse having indulged in a very rich diet, and 
particularly in vegetables and fruits. I do not mean to assert that 
all nursing women should abstain from fruits, or even live on a 
very simple diet, for I have known some who could make use of 
the richest food, and eat abundantly of all kinds of vegetables and 
fruits, without the least injury to their milk. But there are others 
who cannot do this without occasioning indigestion in their infants, 
either because their milk-glands extract something hurtful from 
such food, or that their children are unusually susceptible to the 
action of the materials absorbed from that kind of food. Again, it 
is clearly proved, it seems to me, by recorded cases, and by the 
opinions of various authorities, that the milk of the nurse is affected 
by her moral condition. Children have been known to suffer 
greatly, and even to perish from taking the milk of a nurse who 
had just before undergone a fit of violent anger. The depressing 
moral emotions, as anxiety, grief, fear, and despair, are well 
known to affect the milk secretion, in such a way as sometimes to 
occasion indigestion. 

The use of artificial diet for young infants, or as the expression 
is, " bringing up on hand or the bottle," is, I believe, by far the 
most frequent cause of indigestion during infancy. Very many 
children with whom this is attempted die of indigestions, chronic 
diarrhoeas, gastritis, entero-colitis, and thrush. Very few escape 
frequent attacks of one or other of the diseases just named. 



220 INDIGESTION. 

Much depends, no doubt, on the selection and preparation of the 
food. It may be stated as a well-established fact, that a diet con- 
sisting wholly or in great part of farinaceous substances, very 
rarely fails to disagree with the child, and to produce indigestion 
and other disorders of the digestive system, which often prove fatal ; 
while one in which cow's or goat's milk enters as the principal in- 
gredient, though infinitely inferior to the natural aliment, and often 
productive of indigestion, is far less injurious than the one before 
spoken of. 

A third cause of indigestion was stated to be the absence or 
loss of the digestive power of the stomach, independent of the 
nature of the food. This is a condition similar to the dyspepsia 
of the adult. It may be congenital or may result from causes 
brought into action after birth. It often remains as a consequence 
of previous indigestions from improper or excessive feeding. It 
exists during the invasion, course, and convalescence of various 
diseases. Dentition frequently diminishes or impairs the tone of 
the digestive function, so that the child is often unable, during that 
process, to digest aliment which had agreed with it perfectly well 
at other times. 

The causes of indigestion after the completion of the first denti- 
tion are congenital feebleness of the digestive function ; the want 
of power of that function, which remains often for years in chil- 
dren reared upon artificial diet, and in those who have been debi- 
litated by frequent attacks of disease of any kind ; the habitual use 
of improper diet ; the eating of crude, indigestible food ; the process 
of the second dentition ; the want of due exercise in the open air; 
residence in large cities ; and undue exercise of the mental facul- 
ties in the conduct of the education of the child. 

Symptoms. — I shall describe first the symptoms of indigestion 
as it occurs during infancy, and secondly as it occurs during child- 
hood, or after the completion of the first dentition. 

Indigestion during infancy may be advantageously considered 
under two heads : as occasional or accidental, and as habitual. 
By the former I mean that which occurs in a healthy infant from 
a transient cause, as repletion; a momentarily unhealthy state of 
the nurse's milk from some imprudence on her part as to diet, 



SYMPTOMS. 221 

from a moral cause, or from sickness ; and that which depends 
upon the passing influence of dentition. By habitual indigestion, 
I mean the form of the affection which is long continued in con- 
sequence of a persistence of the cause. 

The symptoms of occasional or accidental indigestion in infants 
are : paleness and contraction of the face ; restlessness and 
peevishness ; moaning and crying, or in some cases, screaming ; 
nausea, shown by excessive paleness, often by very great languor, 
and by occasional retching, which may either subside without vo- 
miting, or as more frequently happens, terminate in that act ; 
flatulent distension and hardness of the abdomen, especially in the 
epigastric region, often accompanied with eructations ; and in 
many of the cases simple diarrhoea. These symptoms usually 
come on soon after nursing freely, or after a very hearty meal of 
artificial food, in a child previously in good health. The attack 
seldom lasts more than a few hours or one or two days. The vo- 
miting which almost always takes . place, and which relieves the 
stomach from the offending cause, very often accomplishes the 
cure. 

Habitual indigestion in infants causes a train of symptoms 
which are different from, and much more severe than those just 
described. Of these the most important are : frequent attacks of 
nausea and vomiting, and of simple diarrhoea repeated for days, 
weeks, or months in succession ; paleness, or some other unhealthy 
tint of the cutaneous surface ; continual restlessness and discom- 
fort, with fretting or crying, particularly in the after part of the day 
and during the evening and night, in place of the natural ease 
and quiet of a healthy infant ; constant fits of the most violent 
screaming from colic, sometimes lasting for hours ; dull and lan- 
guid expression of the countenance, or else an uneasy, contracted 
look, like that produced by continued suffering ; more or less 
emaciation ; failure of the natural growth in stature and size, so 
that the child is small and puny for its age ; want of calorific 
power, causing the child to suffer unusually from cold, as shown 
by frequent coolness of the hands and feet ; irregular appetite, 
which requires to be tempted by frequent changes of the food, or 
more or less complete anorexia ; and lastly, the various symp- 

19* 



222 INDIGESTION. 






toms which indicate an impoverished state of the blood and bad 
nutrition. 

In some cases there are added to the above symptoms, those of 
gastritis or entero-colitis, to be hereafter described. Indigestion 
probably seldom proves fatal in infants, except from the occur- 
rence of some inflammatory complication, as for instance, one of 
the diseases just named, or acute disease of some other principal 
organ. 

Indigestion in children who have completed the first dentition 
may, as in the case of infants, be occasional or habitual. Occa- 
sional indigestion occurs in strong and vigorous, as well as in more 
delicate subjects. The attack generally begins within a few hours 
or a day after the child has eaten some indigestible substance, with 
languor and chilliness in older children, and with languor and 
peevishness in those who are younger ; after which there is head- 
ache, pain in the stomach in most of the cases, and very often a 
disposition to somnolence. If the child is attacked with vomiting 
soon after the appearance of these symptoms, and ejects the offending 
material, it will often seem perfectly well from that time. If, how- 
ever, this does not take place, fever, sometimes of a violent character, 
is almost certain to make its appearance. The pulse becomes very 
frequent, rising to 120, 130, or even higher, and being full and re- 
sisting ; the skin becomes flushed, dry, and very hot; the appear- 
ance of the tongue is not generally changed early in the attack ; 
there is considerable thirst ; the child is restless and uneasy, toss- 
ing from side to side, or lies in an uneasy sleep, attended with fre- 
quent starting and jerking of the limbs or crying out ; the abdomen 
is natural, or hard and distended over the epigastric region. When 
the symptoms just described make their appearance suddenly, by 
which I mean in the course of a few hours, in a child two, three, 
four or five years old, after it has eaten some indigestible sub- 
stance, there is reason to fear an attack of convulsions. The pro- 
bability of the occurrence of this accident is great in proportion to 
the earliness of the child's age, and the impressibility of its ner- 
vous system. The attack is particularly to be apprehended, and 
should be carefully guarded against, whenever the fever is violent, 
when there are urgent complaints of headache, when the restless- 



SYMPTOMS. 223 

ness and agitation are very great, or when there is somnolence, with 
frequent startings or twitchings of the muscles. Convulsions some- 
times occur without any previous warning, or after such slight 
signs of disorder as would fail to produce uneasiness in the parents 
or attendants. 

The symptoms produced by occasional indigestion generally 
continue until nature relieves the stomach by vomiting or diar- 
rhoea, or until the remedies proper in the case, the most impor- 
tant of which are evacuants, have been administered. It hap- 
pens not unfrequently that symptoms of gastric or intestinal dis- 
order remain for some days after the violence of the attack has 
subsided, and in some instances the disturbance is so great as to 
occasion gastritis, entero-colitis, or dysentery. 

Habitual indigestion in children who have completed the 
first dentition, is not at all an uncommon affection. It is a condi- 
tion analogous to, if not identical with, the dyspepsia of the adult. 
The symptoms of this form are the following. The general ap- 
pearance of the child is delicate, as shown by a pallid or sallow 
tint of the skin, instead of the ruddy complexion of health, by 
thinness and want of proper development of the limbs and trunk, 
and by softness and flaccidity of the muscular tissues. There 
is an habitual air of languor and listlessness, with absence of the 
usual gaiety and disposition to play natural to the age, and the 
child often complains of being tired. The appetite is feeble or 
uncertain, being sometimes absent, and at other times too great ; 
or it is peculiar, the child being willing to eat of dainties, but re- 
fusing food of a simple character. The tongue presents nothing 
peculiar. It is however more frequently somewhat furred than clean 
and natural. The temper is usually irritable and uncertain. The 
child rarely sleeps well ; on the contrary, the nights are restless 
and much disturbed, the sleep being broken and interrupted by 
turning and rolling, by moaning or crying out, and by grinding of 
the teeth. These latter symptoms, together with the picking at 
the nose, which is a frequent accompaniment, are almost always 
referred by the parents and nurses to worms, and it is often im- 
possible to convince them to the contrary, even though frequent 
and violent doses of vermifuges have failed to show the existence 



224 INDIGESTION. 

of entozoa. The state of the bowels is uncertain. In some in- 
stances they are very much constipated, requiring frequent doses 
of laxatives, or careful regulation of the diet, to keep them solu- 
ble ; in others they are inclined to be loose, and when this hap- 
pens, the stools are often lienteric. In others, again, constipation 
and diarrhoea alternate. The abdomen is usually natural, or some- 
what enlarged from flatulent distension ; complaints of pain are not 
uncommon. This form of indigestion, like dyspepsia in the adult, 
is generally a very chronic affection, seldom lasting less than seve- 
ral weeks or months, and sometimes for years. 

Diagnosis. — The occasional indigestion of infants is not likely 
to be mistaken for any other complaint. The suddenness of the 
attack, the character and quantity of the matters ejected from the 
stomach, the absence of symptoms indicating the invasion of any 
other disorder, the short duration of the symptoms, and the rapid 
recovery, all render the true nature of the case very clear. That 
which occurs in older children, on the contrary, is not so easy of 
diagnosis. In many cases the invasion is not unlike that of scarlet 
fever. The vomiting and frequency of the pulse, the great heat 
of the skin, and in some cases a certain suffusion of the integument 
dependent on the activity of the circulation, all render the case 
doubtful for some hours, or for a day, after which time the diffi- 
culty ceases, from the development of the symptoms peculiar to 
each disorder. I believe that not a i"ew cases of simple angina 
are mistaken for indigestion, owing to the absence of complaints 
of sore throat, and the neglect of the physician to examine that 
part. In such cases the vomiting and sudden attack of fever 
are ascribed, for the want of another mode of explaining them, to 
gastric derangement. The diagnosis can be made only by exami- 
nation of the fauces. The diagnosis of indigestion accompanied 
by convulsions will be considered in the article on the latter 
affection. 

The habitual indigestion of infants is not likely to be confounded 
with any other disease. The absence of fever, of tenderness of 
the abdomen on pressure, or other acute symptoms, all indicate 
the dependence of the disorder on functional distress of the stomach. 
The same remarks apply to this form of the disease occurring in 



PROGNOSIS TREATMENT. 225 

older children. Nevertheless, the practitioner should never neglect 
to make a careful examination, both of the physical and rational 
signs, of all the important organs of the body, as it sometimes 
happens that latent disease of some one of them is the cause of 
the gastric difficulty. 

Prognosis. — The prognosis of occasional indigestion is nearly 
always favourable. It is rarely a dangerous disorder, unless 
accompanied by convulsions, or some other signs of violent dis- 
turbance of the nervous system. Under the latter circumstances, 
the prognosis should be very cautious, as the termination is not 
unfrequently fatal in consequence of injury done to the nervous 
centres. It should be recollected also that this form of indigestion 
sometimes becomes the exciting cause of inflammation of the 
stomach or intestines, in which event the prognosis will be that of 
those diseases. 

Habitual indigestion in infants is a serious complaint, and ought 
always to awaken the solicitude both of the physician and parents ; 
for though a simple functional disease of the stomach is not pro- 
bably often fatal, it is exceedingly apt to prove so by the induction 
of gastritis, chronic enteritis, colitis, or thrush, or by its laying the 
system open to other diseases, and rendering it less able to with- 
stand them, should they happen to occur. In older children it is 
not, according to my experience, so dangerous a malady. I have 
never as yet seen it terminate fatally. 

Treatment. — The treatment of occasional indigestion in infants 
ought to be very simple. The child has generally relieved itself 
by vomiting before the physician is called. If, however, it con- 
tinues pale and languid, with vomiting or retching after the 
stomach seems to have been emptied, the proper plan is to make 
use of remedies to calm the irritability of the organ. This can 
almost always be accomplished by giving a teaspoonful every ten 
or fifteen minutes, of a mixture of lime water and milk, consisting 
of one-third milk to two-thirds lime water, or of equal proportions 
of each. At the same time a small mustard plaster, weakened 
with wheat flour, may be applied to the epigastrium, or a warm 
indian mush poultice in a flannel bag, laid over the whole ab- 
domen. Should these means fail to relieve the sickness, from 



226 INDIGESTION. 

half a drop to a drop of laudanum, or two drops of paregoric may 
be administered, and repeated if necessary in two hours. The 
child generally recovers its usual health after the sickness has 
entirely ceased. If, however, it remain fretful and uneasy, if it 
cry much as though in pain, it is probable that a portion of 
aliment has passed in a partially or wholly undigested state into 
the intestine. The suspicion will be confirmed if the abdomen is 
found upon palpation and percussion to be swelled, hard, and re- 
sonant from flatulent collections in the bowels. Under these cir- 
cumstances, a laxative ought to be given. The best dose is half a 
tea spoonful or a teaspoonful of castor oil, a teaspoonful of simple 
or spiced syrup of rhubarb, or, if there have been evidences of an 
acid state of the stomach, from a quarter to a third of a teaspoonful 
of the best, magnesia. 

The occasional indigestion of older children demands a different 
and more energetic treatment. After ascertaining that the child 
has eaten something indigestible, we should inquire whether there 
has been vomiting. If there has been none, or if only slight, 
it will be proper to give an emetic immediately. The best 
one under the circumstances is ipecacuanha. This rarely fails 
to produce a full effect, and does not perturbate the system, or 
irritate the stomach like tartar emetic. It may be given either 
in powder or syrup. The dose is familiar to every one. If 
the ipecacuanha be not at hand, we may use hive syrup, which 
is kept in almost every house, or a teaspoonful of powdered 
alum in honey or molasses, to be repeated, if necessary, in 
fifteen minutes. Alum is less apt to fail than either ipecacuanha 
or hive syrup. If the child continue unwell after the operation 
of the emetic, which is often the case, and particularly if the fever 
be considerable, a purgative should be given as soon as the sto- 
mach will bear it. The best dose is castor oil, which is the most 
speedy and least irritating. It may be given in orange juice, which 
forms an excellent vehicle, or, if the child is old enough, in the 
froth of beer or porter. A dessert-spoonful is generally enough. 
If the oil cannot be taken, we may give infusion of senna and 
manna, the fluid extract of senna mixed with spiced syrup of rhu- 
barb, syrup of rhubarb alone, magnesia to be followed by lemon- 



TREATMENT. 227 

ade, salts and magnesia or the former alone, or lastly a sedlitz 
powder. If the fever continue, and the cathartic fail to operate in 
four or six hours, a purgative enema ought to be given to hasten 
its effect. A bath at about 96° or 97° will almost always be 
found useful in these cases. The child should be kept in the bath 
from eight to twelve or fifteen minutes. The only circumstances 
which form an objection to this remedy are the facts of the patient 
being so irritable, or so fearful of the water, as to make it neces- 
sary to contend with him in order to succeed in using it. When 
this is the case it had better not be employed, and sponging with 
tepid water and spirit should be substituted. If the child complains 
of pain in the stomach, the application of a warm mush poultice 
over the epigastrium or whole abdomen will be found of much 
service. 

When, in this form of indigestion, the febrile reaction is violent 
as it often is, and particularly when there are signs of great dis 
turbance of the nervous system, consisting of excessive agitation, 
complaints of severe headache, drowsiness, moaning or crying out 
in the sleep, or twitching and jerking of the muscles, the physi- 
cian should beware of a convulsive attack. In such cases as these 
the patient ought to take a purgative dose of calomel (from three 
to four grains), have a warm bath at once, soon after an injection, 
and if not considerably relieved in a very few hours, be bled at the 
arm to three or six ounces. The remedies ought to be prompt 
and energetic, for the case is pressing. A convulsion is always a 
dangerous event in childhood, and should be prevented, if possible. 
About two hours after the calomel has been given, a cathartic dose 
had better be administered, in order to insure an action upon the 
bowels, and to carry the calomel out of the system. These means 
rarely fail to afford relief in a few hours. The diet should be 
absolute during the violent stage of the attack, and the usual diet 
is to be resumed only by degrees. The drinks may be plain 
water or gum water taken cold. 

It not unfrequently happens that occasional indigestion is fol- 
lowed by gastritis or enteritis, or by habitual indigestion lasting for 
weeks or even months. These different sequeloe must be treated 
according to the plan proper for each. 



228 INDIGESTION. 

The habitual indigestion of both infants and older children re- 
quires a very different treatment from the occasional or accidental 
form. In both the indications are nearly the same. The most 
important are very careful regulation of the diet in all its details, 
the use of tonics and stimulants, to restore tone and vigour to the 
digestive function, the employment of remedies to correct the state 
of the bowels, whether they be relaxed or constipated, and atten- 
tion to securing the child proper exercise, exposure to the air, and 
suitable clothing. 

If the symptoms of the disorder occur in a child at the breast, 
the milk of the nurse should be carefully examined in order to 
ascertain whether it be good. If found to possess any unhealthy 
qualities, the nurse ought to be changed at once. Attention to this 
point alone will almost certainly cure the child. It needs no other 
remedy. 

If the patient is fed wholly or in part, it is essential to regu- 
late the diet to suit the state of the digestive function. Milk 
ought in all cases to form the basis of the food, unless it has 
been found by patient trial to be absolutely repugnant to the sto- 
mach. I have often found that infants who had been thought 
quite incapable of digesting cow's milk, could do so very readily 
when it was very much weakened with water. The usual propor- 
tions for an infant of a few months old, are half and half, or two 
parts milk for one of water. When these are found to disagree, it 
is well to try three, or even four or five parts of water to one of 
milk, and if the stomach digest this, as it often will, the proportion 
of milk may be slowly and cautiously increased to the usual stan- 
dard. If we conclude that milk cannot be digested by the child, 
it is best to try cream. Of this, one part to three or four of water, 
may be given. When neither of these can be taken, some of the 
farinaceous substances may be tried; arrow-root, sago, barley, 
tapioca, oatmeal, or rice. I am clearly of opinion, however, that 
these articles prepared with water alone, rarely agree with chil- 
dren when they are continued for any considerable length of time. 
Some infants of six or eight months old, it may be remarked, who 
cannot digest more than very small quantities of milk, will take 
and digest well, very delicate broths made of chicken or mutton, 



TREATMENT. 229 

or small quantities of the lightest meats, as mutton, chicken, or 
very tender beef, minced up extremely fine, and given by teaspoon- 
fuls. 

In cases of this kind I have found a diet consisting of gelatine, 
milk, cream, and arrow-root, prepared in the manner directed in 
the article on thrush, (see page 193), to suit better than anything 
else. I have met with several children, and with two in particular, 
whom it was necessary to feed to the amount of a pint or a pint and a 
half a day, in addition to being nursed occasionally, who could take 
neither milk and water, cream and water, milk and arrow-root, oat- 
meal gruel, rice gruel, nor indeed anything that was tried, without 
vomiting, colic, and severe diarrhoea, who digested perfectly well 
and throve admirably upon the preparation alluded to. I have 
now used it during more than a year, and have recommended it for 
a great many children, and do not hesitate to say that it agrees 
with a larger number than any other diet I have ever employed 
or seen employed. 

The diet of older children labouring under chronic weakness of 
the digestive function is as important as that of infants. Two 
chief ends should always be borne in mind in selecting it, digesti- 
bility and nutritiousness. The former is all important, for without 
it, the stomach, constantly irritated by improper food, has no chance 
of regaining its tone, while the latter is necessary in order to sus- 
tain the strength of the child, and allow it to carry on its growth. 
I have generally found it most prudent, and often really necessary, 
to specify as to the substances to be given at each meal. The 
morning and evening meal ought to consist of bread and milk, 
mush and milk, or of milk, warm water and sugar (called in this 
country children's or cambric tea), and bread and butter, and no- 
thing else in most of the cases. It is sometimes proper to allow a soft 
boiled egg, particularly if the child be very fond of it. The dinner 
ought to consist of light broths containing rice, with bread or toast, 
or of the plain meats, as mutton, beef, chickens, turkeys, birds, or 
fine game. No vegetable ought to be allowed in most of the cases 
except rice, as all others, even the potato, are very apt to disagree. 
I believe that the potato is more digestible when roasted than 
when boiled. If the child require anything between breakfast and 

20 



230 INDIGESTION. 

dinner, it may have what is allowed at breakfast, or dry bread, 
and nothing else. There are various articles of diet which should 
be absolutely forbidden, amongst which are hot and sweet cakes, 
and hot bread of all kinds ; sausages, not unfrequently given to 
children in this country ; corn-beef, ham, veal, pork, goose, ducks, 
fish ; all manner of dessert, except rice pudding, or curds and 
whey, often called junket; sweetmeats, candies, fruits, except 
some of our finest summer ones ; and to conclude, everything 
which long observation and experience have shown to be un- 
suitable for a dyspeptic stomach. 

It is sometimes very difficult to find anything to agree well with 
the child. In one case of a child three years old that came under 
my observation, neither milk, bread, nor meat, could be taken. 
The caseum of milk seemed to be absolutely indigestible, as it 
would be rejected from the stomach many hours, or even a day or 
two after the milk had been taken, in the form of masses of dry, 
fibrous cheese, of an oblong shape, nearly or quite as large as a 
peach-stone. After trying various articles I found that the child 
digested raw oysters, soda biscuit, and rennet-whey, and upon 
these articles alone she lived for two weeks, at the end of which 
time she had improved so much as to be able to take the white 
meat of chicken very finely minced, and gradually regained her 
previous health. 

After regulating the diet, such remedies as tend to invigorate 
the digestive function ought to be prescribed. The most important 
of these are the vegetable and mineral tonics, and mild stimulants. 
I have found quinine, iron, and small quantities of port-wine or 
brandy, to succeed better than anything else. To a child under 
two years old, from a quarter to half a grain of quinine, and to one 
over that age, a grain, may be given three times a day, and con- 
tinued for two, three, or four weeks. It is best given to young 
children diffused, without being dissolved, in a mixture of equal 
parts of syrup of gum and ginger; while to those who are older 
it may be administered in pill. The best preparations of iron are 
the iodide, or the pure metallic iron prepared with hydrogen. Of 
the former, half a drop to one drop for infants, and from one to two 
drops for older children, may be given three times a day ; of the 



TREATMENT. 231 

latter a quarter of a grain for infants, and half a grain to a grain 
for those who are above that age, may be given three times a day. 
The metallic iron is best administered in pill or suspended in syrup 
of gum arabic. When there is any suspicion of a scrofulous taint in 
the child's constitution, or when it is disposed to have chronic irri- 
tations, excoriations, or ulcerations of the nostrils, or papulae or 
pustules about the eyelids or other parts of the body, it is useful 
to give the iron in compound syrup of sarsaparilla, of which half 
a teaspoonful three times a day is quite enough. In connexion 
with these remedies a little port- wine or brandy, and the former is 
preferable in children over a few years old, on account of the pos- 
sibility of their contracting a taste for the brandy, may be allowed 
twice or three times a day, or at dinner only. To young children 
one or two teaspoonfuls of brandy may be given in the course of 
the day, mixed in water ; of the port-wine from a teaspoonful to a 
tablespoonful, according to the age and strength of the patient, 
may be repeated morning, noon, and night. 

If the bowels are inclined to constipation, they should be kept 
soluble by laxative enemata, and by the use of rhubarb or aloes ; 
when relaxed, the frequency of the discharges may be controlled 
by the cretaceous mixture, by anodyne enemata given once or 
twice a day, by the aromatic syrup of galls, (to be described under 
the head of entero-colitis,) or by some of the astringents in com- 
mon use. 

In all cases of chronic indigestion in children, it ought to be re- 
garded as an essential part of the treatment to secure to the patient 
a proper amount of exercise in the open air. In summer the 
child should pass several hours of every day in the air. It ought, 
indeed, if the heat of the sun can be avoided by proper shade, to 
pass the whole day in this way. In winter it is, of course, impos- 
,; ble to carry this system to the same extent, but the child should 
nevertheless be taken out at least once a day ; this may be done 
in the coldest, and even in damp weather, if sufficient clothing be 
worn. If a child comes back from a walk with warm limbs, and 
with its cheeks in a glow, there is little danger of cold. The 
quantity of clothing must depend on the constitution and idiosyn- 
crasy of the patient. Some need twice as much as others. The 



232 SIMPLE DIARRHOEA. 

proper amount is best determined by the temperature and colora- 
tion of the surface after a walk. 



ARTICLE II. 

SIMPLE DIARRHOEA. 

General remarks. — I have already said that I should treat of 
two different morbid conditions of the intestinal tube, one in which 
there is no evident anatomical lesion to explain the symptoms, and 
which appears to depend on simple functional derangement, to be 
designated by the title of simple diarrhoea ; and another in which 
there is evident inflammation with its results, to be described under 
the titles of entero-colitis and cholera infantum. The reasons for 
adopting this division have already been given in the general re- 
marks upon the diseases of the stomach and intestines, and it is 
unnecessary to repeat them at this place. 

Dewees, Eberle, and other writers treat of the diseases of the 
intestines under two heads only, those of diarrhoea and cholera 
infantum. Stewart and Condie treat of the same diseases, but de- 
scribe inflammation of the intestines also, by the titles of enteritis 
and colitis. Most of these writers make different forms of diar- 
rhoea, the feculent, bilious, mucous, chylous and lienteric, and it 
would seem most natural that I should follow the same plan. I 
am disposed to believe, however, that they ought not to be regarded 
as constituting separate and essential morbid conditions of the in- 
testinal tube, but that they are, on the contrary, merely degrees or 
stages of simple diarrhoea or functional derangement, and entero- 
colitis or inflammation of the intestines. We may in fact have 
feculent, bilious, mucous, or lienteric discharges at different stages 
of both these diseased conditions. It seems to me most proper 
therefore not to consider them as distinct affections, though I shall 
continue to employ the terms, in order to express the characters 
of the diarrhoea in different diseases of the intestinal tube. 1 
would remark in further elucidation of this point, that the feculent 
diarrhoea of the above authors, comes as a general rule within the 
class of simple diarrhoea, whilst in other instances it is merely one 



DEFINITION FREQUENCY CAUSES. 233 

of the symptoms of the first stage of entero-colitis ; and that the 
bilious, mucous, and lienteric diarrhoea may exist both in the 
functional and inflammatory diseases of the bowels. 

Definition ; frequency. — By simple diarrhoea, I mean the form 
of diarrhoea which exists without perceptible signs of inflamma- 
tory action in the intestine ; which is known by post-mortem ex- 
aminations to occur without appreciable anatomical lesions*; and 
which we must conclude, therefore, to depend on simple func- 
tional derangement. 

It is undoubtedly a very frequent ailment in children, more es- 
pecially from birth to the termination of the first dentition. It is 
of common, though of less frequent occurrence from the last men- 
tioned period to the age of eight or ten years, after which, accord- 
ing to my experience, it becomes rare. 

Causes. — The causes of the disease during infancy are unfa- 
vourable hygienic conditions, as the habitation of unwholesome, 
ill-ventilated, damp, and filthy dwellings, or of contracted and 
crowded quarters of cities and towns ; an unhealthy state of the 
milk of the nurse ; the use of artificial diet at too early an age, 
especially when badly chosen; cold; dentition; and lastly, great 
atmospheric heats. The most important of these are improper 
alimentation, by which I mean the use of artificial diet, and par- 
ticularly one consisting chiefly of farinaceous substances to the 
exclusion of a proper amount of milk, and dentition. For a fuller 
account of the influence of these different circumstances on the 
digestive organs of children, the reader is referred to the remarks 
on the causes of entero-colitis. 

The chief causes of the disease after the first dentition are, ac- 
cording to my experience: the habitual use of 'improper food ; the 
loss of digestive power, which often follows a severe indigestion, or 
an attack of some acute disease; the debility of constitution which 
attends sudden and rapid growth; the want of proper exercise and 
exposure to the air; the predisposition which exists in some chil- 
dren from hereditary causes ; and the disturbing influence of the 
second dentition. 

The system of indiscriminate diet allowed to children in this 
country is, it seems to me, a fruitful cause of gastric and intestinal 

20* 



234 SIMPLE DIARRHCEA. 

complaints. I believe that, as a general rule, children over two 
and three years of age, are allowed amongst us to eat of the food 
prepared for the older members of the family. Now, any one 
who will reflect upon the variety of dishes habitually placed 
upon an American table, ought not to be surprised to see chil- 
dren permitted a choice amidst such profusion, pale, thin, deli- 
cate, 'exposed to frequent indigestions, attacks of diarrhoea and en- 
tero-colitis, to gastric fevers, and the host of minor ills attendant 
upon feeble digestive powers. I am acquainted with some families 
in this city, the children of which, from the age of two years, are 
allowed habitually to breakfast upon hot rolls and butter, hot buck- 
wheat cakes, hot indian cakes vulgarly called dabs, rice-cakes, 
sausages, salt fish, ham or dried beef, and coffee or lea ; to dine 
upon a choice of various meats and a great variety of vegetables, 
which latter they often prefer to the exclusion of meat, and then 
to make a rich dessert of pies, puddings, preserves, or fruits ; and 
lastly to make an evening meal of tea and bread and butter almost 
always relished, as the term is, with preserves, stewed fruits, hot 
cakes of some kind, or with radishes, cucumbers, or some similar 
dish. Add to such meals as the above the eating between whiles 
of all kinds of candies and comfits, which children here regularly 
expect in larger or smaller quantity, cakes both rich and plain, 
fruits to excess and at all hours from soon after breakfast to just 
before going to bed, raisins and almonds, and nuts of various kinds, 
and the wonder is not that we are a pale, thin, dyspeptic, and 
anxious-looking race of people, compared with Europeans, but that 
we have any health at all, when our children are allowed to make 
use of the indiscriminate and unwholesome diet just described. 
Such a system undoubtedly occasions frequent attacks of the dis- 
ease under consideration, and unless the diet be changed early in 
the attack, it is very apt to become chronic. It has been stated 
that simple diarrhoea sometimes followed as a consequence of in- 
digestion. I have known such a result to occur in children pre- 
viously in fine health, and to continue for several weeks or months. 
In these instances, the disorder appears to depend in good measure 
on the loss of the digestive power of the stomach. This seems 
proved by the great influence which the character of the food has 



CAUSES SYMPTOMS. 285 

upon the malady, which is always aggravated by the use of any 
articles except those universally acknowledged to be the most 
digestible, and also by the frequent co-existence of lientery when 
the food is not of the lightest kind. 

I have several times met with cases which I could ascribe to no 
other cause than debility and want of power of the digestive 
organs, dependent upon too rapid growth. That sudden and rapid 
growth may produce feeble digestion, or, in other words, a dys- 
peptic state, is, in my opinion, proved by the following considera- 
tion. It is attended with loss of appetite, emaciation, paleness, 
languor and weakness, and frequent attacks of diarrhoea, or a 
chronic form of that disorder ; all of which symptoms are greatly 
influenced by the regimen of the child, and are most readily re- 
moved by attention to that point, and by the use of tonics and 
stimulants. 

The other causes enumerated need but little comment. I will 
merely remark that I have several times observed a predisposition 
to weakness of the digestive organs, transmitted apparently from 
parent to child. As to the influence of the second dentition, I 
have no doubt that it is a frequent cause of the complaint, and 
believe that it is too little attended to by practitioners. 

Symptoms. — I shall describe first the symptoms of simple 
diarrhoea in infants, and afterwards those which characterize the 
disorder in older children. In infants the appearance of the diar- 
rhoea is usually preceded or accompanied by slight disturbance of 
the temper and comfort of the child. There is some degree of 
restlessness, peevishness, and disposition to cry ; the child sleeps 
less than usual, and often starts and moans during sleep ; all of 
which symptoms are more marked, as is the case indeed in nearly 
all the ailments of children, during the night. Though the symp- 
toms described are observed from time to time, and particularly 
during the night, they are not always present, as the infant 
will occasionally through the day seem perfectly well and com- 
fortable, with the exception perhaps of slight paleness and lan- 
guor, almost always perceptible upon its countenance. There 
is no fever in these cases, or at least nothing more than un- 
usual warmth of the hands, feet, and abdomen, at night. U a 



236 SIMPLE DIAREHffiA. 

marked febrile reaction take place, there would be reason to sus- 
pect the existence of some degree of entero-colitis. The mouth 
often becomes, after a few days, a little warmer and less moist 
than usual ; the tongue is generally moist and only slightly coated ; 
and the appetite is commonly diminished, as shown by the child's 
nursing with less eagerness and at longer intervals than before. 
In very mild cases the stools are at first, and sometimes through- 
out the attack, feculent ; the only differences from their ordinary 
characters which occur, being that they are more frequent, 
thinner, more copious than usual, and that the odour is changed 
so as to become acrid and offensive. In severe cases, the stools 
contain less feculent matter, become yet more fluid and sometimes 
watery, and exhibit small particles of a greenish colour, scattered 
through them ; or the whole of the discharge is of a deep green colour, 
and is intermixed with portions of mucus. In many of the cases, 
whitish lumps, evidently consisting of undigested curd, are observed 
mixed with the other substances upon the napkin. The number of 
stools varies from two, three or four, to six or eight in the twenty- 
four hours. The number last mentioned is seldom exceeded, so long 
as the diarrhoea remains simple. The abdomen is seldom distended, 
or painful to the touch. The general appearance of the child almost 
always shows the effects of the malady upon the constitution, after 
a few days. The countenance becomes paler and thinner ; the 
eyes look somewhat hollow ; the edges of the orbits are more de- 
fined, and often present a pale bluish circle ; slight emaciation 
takes place, and the flesh of the child becomes softer and more 
relaxed than before the attack. The duration of the disorder is 
generally short, as it seldom lasts more than three or four days, 
or a week. It may terminate in complete restoration to health, 
without its having exposed the life of the child to danger, or, if 
the causes which gave rise to it continue in action, if the child 
is of delicate constitution or the treatment not correct, and espe- 
cially if of too perturbating a character, it is very apt to run into 
entero-colitis, and expose the patient to all the dangers of that 
disease. 

In older children (after the first dentition), the disease is much 
less frequent than in infants, and presents a different train of 
symptoms. Often it is nothing more than slight disorder of the 



i SYMPTOMS. 237 

bowels, amounting to three, four, or five stools, thinner and more 
abundant than usual, accompanied by slight colicky pains, and 
unattended by fever or other signs of sickness, which, after 
continuing for one, two, or three days, ceases, and the child re- 
gains its usual health. Some children are particularly liable to 
these attacks, and suffer from them every few weeks, or after any 
indiscretion in diet ; whilst, in others they are rare, let the diet be 
what it may. 

There is another form of simple diarrhoea, however, of which I 
have seen nine cases, much more troublesome than the one just 
described. It occurs in children from two and a half to seven 
and eight years of age, lasts a considerably longer time, and is 
much less under the control of remedial measures. This form of 
the disease has never in the cases that I have seen, been accom- 
panied by fever, or by any constitutional symptoms rendering it 
necessary to confine the child either to the bed or house. The 
only symptoms beside the diarrhoea which I have observed, have 
been some degree of paleness, and moderate emaciation ; slight 
weakness, shown by an indisposition on the part of the child to play 
with its usual spirit, by an inclination to lie about from time to time 
through the day on the sofa or floor, and by complaints of "being 
tired ;" irritability of temper and peevishness ; irregular appetite ; 
picking of the nose; and restless, disturbed sleep at night, attended 
with moaning, crying, starting, and grinding of the teeth ; all of 
which symptoms generally convince the mother that the child is 
suffering from worms. The abdomen is sometimes slightly tumid, 
but remains natural as to tension, and is not painful on pressure. 
There is no pain except slight colics in some cases. The stools 
have generally numbered from three to five, and in a few cases as 
many as six or eight a day. They are semi fluid in consistence, 
often of a very offensive odour, and consist usually of feculent 
matter, which is sometimes clay-coloured, more frequently dark- 
brown, and, in other instances, deep yellow or orange in colour. 
They are often also of a frothy character. In two of the nine 
cases that I have seen, there was lientery whenever the aliment was 
otherwise than of the lightest and most digestible kind. In all, the 
diarrhoea was evidently greatly influenced by the diet, showing, it 



238 SIMPLE DIARRHOEA. 

appeared to me, an intimate dependence of the malady upon the 
condition of the stomach, which seemed to have lost in a greater 
or less degree its digestive power. 

The course of the disease in this form was variable. In some 
it would last a few weeks, and then, under the influence of diet 
and remedies, cease, to recur and run the same course after a short 
period. In others it has lasted a much longer time in spite of all 
treatment that I attempted. In three of the cases it continued 
between three and four months, with occasional slight remissions, 
brought about apparently by remedies which a day or two after would 
seem to lose their effect. In two others it lasted about two months ; 
in another six weeks ; in another a month ; in the remaining two 
cases the exact duration is not recollected. 

Diagnosis. — The diagnosis of simple diarrhoea will rarely pre- 
sent any difficulties, since there is nothing with which it could be 
confounded, except the diarrhoea from tubercular ulceration of the 
bowels, or entero-colitis. From the former it is to be distinguished 
by the history of the case, and by the signs of tuberculization in 
other parts of the economy ; from the latter by the absence of 
signs of inflammatory action. 

Prognosis. — The prognosis is favourable so long as the disease 
remains simple. The physician should never forget, however, 
the disposition which is inherent in it to pass into entero-colitis, 
nor fail to make the possible occurrence of this transition one 
element in his prognosis. During infancy it is always more 
serious than after that period, from the feebler power of resistance 
on the part of the constitution to disease at that age, which un- 
doubtedly allows this simple affection to prove fatal in some in- 
stances, probably from the shock to the nervous system. After 
infancy it is rarely a dangerous disorder, both because of the 
greater stamina existing at that age, and from the fact that the 
disposition to extension of disease is less strong. 

Treatment. — The prophylactic management of simple diarrhoea 
is the same as that which is proper for entero-colitis, and as that 
affection will be treated of at considerable length in a future article, 
I must, on account of my limited space, refer the reader there for 
information on this point. 



TREATMENT. 239 

After the disease is established the treatment must consist first 
in attention to the diet, exercise, and state of the gums of the child. 
In many cases, careful regulation of the diet and exercise, and 
lancing the gums when they are much distended and vascular 
from the pressure of the advancing teeth, will suffice to arrest 
the disorder in a few days, without the necessity of resorting to 
drugs, which ought certainly to be avoided whenever it is possible 
to do so. If the child is at the breast, we must ascertain whether 
the milk of the nurse is good, by inquiry as to its appearance, by 
examination with the microscope, and by reference to her health, 
diet, temper, &c, all of which circumstances more or less affect 
the mammary secretion. If we conclude that the milk is good, or 
that it has been disturbed in its healthy properties only by a tran- 
sient cause, the child must be continued at the breast, with the 
precaution, however, of not allowing it to nurse quite as much as 
usual. An infant suffering from any kind of diarrhoea, had better 
be restricted entirely to the breast, unless it be clear that the supply 
of milk is quite insufficient. If we determine that the milk is un- 
healthy, the nurse must either be changed, or the child weaned ; 
of course the former alternative is infinitely preferable if the child 
is under a year old, or even eighteen months if it seems to have a 
rather delicate constitution. 

If the case occur in a child already weaned, or in one fed partly 
on artificial diet, the regulation of the kind, preparation, and quan- 
tity of aliment is of the utmost consequence. It ought to consist 
chiefly of milk or cream weakened with water, unless it has been 
clearly shown by previous trial that these articles do not agree 
with the child. I prefer before any kind of diet that I have ever 
employed, or known to be employed, that made from cow's milk, 
cream, arrow-root, and gelatine, in the manner described at 
page 193. The proportions of the milk, cream, and arrow-root, 
must vary with the age and digestive power of the patient. I 
will merely state, as a general principle, that during the existence 
of diarrhoea, or at least the early stage of it, and before the 
strength has been reduced by the disorder, the proportions of 
cream and milk ought to be considerably less than in health. 
Not only this, but the total quantity of food in the day should 
be diminished, unless the ordinary amount seems to be really 



j. 



240 SIMPLE DIARRHC3A. 

necessary for the sustentation of the strength. If it be found, how- 
ever, after patient trial, that the child either will not take, or does 
not digest this kind of food, we may try arrow-root or rice water, 
thin gruel or panada, alternated with very carefully prepared 
chicken or mutton water. If the child is six or eight months old, 
it often suits well to allow it a piece of juicy beef or a chicken 
bone to suck, or from one to several teaspoonfuls of meat of 
chicken or mutton minced very fine. 

For older children with a common attack of simple diarrhoea, 
the diet should consist for a i"ew days of boiled milk with bread 
of gruels made wilh boiled milk and arrow-root, rice-flour, sago, 
tapioca, or common wheat flour, and of small quantities of light 
broths. Meats are, for the time, improper, and all vegetables, with 
the exception of rice, yet worse. 

In the cases of infants it is best to recommend a continuation of 
the ordinary exercise, unless the weather be cold and damp. In- 
deed, in good weather, exposure to the air and proper insolation 
are more important during the existence of this disorder than even 
during health. The same remarks apply to older children, with 
the exception that they ought not to be allowed to fatigue them- 
selves, particularly in warm weather, as this would have a tendency 
to aggravate the complaint. 

When the disorder occurs in a teething child, the gums ought 
always to be examined by the physician, and if found swelled, 
vascular, of a deeply red colour, and hot, with the outline of the 
advancing tooth perceptible, they should be freely incised to the 
tooth. If, on the contrary, the tooth is too deep to be felt, I would 
advise only a slight -and superficial scarification in order to relieve 
the tension of the gum, and yet to avoid coming in contact with 
the tooth, which is sometimes injured by the lancet, when touched 
before the deposit of enamel is fully completed. 

The therapeutical management of the disease should be as simple 
as possible. The fewer drugs we can succeed with in the gastro- 
intestinal complaints of infants and children, the better, it seems to 
me. When, however, the diarrhoea continues for some days in 
spite of attention to the points already mentioned, we must resort 
to some of the means which have been found most useful in check- 



TREATMENT. 241 

ing the inordinate action of the bowels. The most important are 
a careful employment of laxatives and the use of opiates and 
astringents. I have generally commenced the treatment by the 
exhibition of a teaspoonful of castor oil, containing from half a drop 
to a drop of laudanum, for young infants, and two drops for older 
children. This dose alone given for two evenings in succession 
has oftentimes sufficed to effect the cure. If the diarrhoea persists 
after this, we must resort to some of the astringents. The one 
most commonly employed is the chalk mixture, which is officinal 
in our pharmacopoeia. A teaspoonful of this is to be given after 
each loose evacuation, or three or four times a day. If the case 
prove obstinate, it will be found useful to add to each dose of the 
chalk preparation, a small quantity of laudanum or paregoric, or 
some astringent tincture, the best of which is the tincture of kra- 
meria. When the chalk mixture fails entirely, powdered crab's 
eyes will sometimes succeed ; or we may resort to the aromatic 
syrup of nut-galls. The formulas and doses for both these remedies 
will be found in the article on entero-colitis. If the discharges are 
small and frequent, mixed with mucus and somewhat painful, it 
will be found that small opiate injections, (from one to two drops 
of laudanum in a tablespoonful of prepared starch for young 
infants, and from three to six drops in double the quantity for 
older children,) or the use of Dover's powder in combination with 
chalk or sugar of lead, will often succeed in arresting the disease. 
For further and more complete information in regard to astrin- 
gents, I must refer the reader to the article on entero-colitis, where 
they will be fully discussed. 

The chronic form of simple diarrhoea which I have attempted 
to describe, occurring in children who have completed the first 
dentition, has always proved difficult to manage. From the ex- 
perience I have had, it seems to me that the best mode of treating 
it is by proper regulation of the diet, and by the use of tonics and 
stimulants, and occasionally of opiates. I was led to adopt this 
plan in consequence of having failed entirely to control the symp- 
toms by the treatment generally successful in simple diarrhoea, and 
by the opinion which I came at last to form, that the disease de- 
pended in great part on a loss of the digestive power of the stomach 

21 



242 SIMPLE DIARRHCEA. 

and duodenum. The diet must depend on the peculiarity of the 
individual ; what we should seek is such an one as will be easily- 
digested by the patient, the materials of which shall not appear 
in the stools, and one which does not manifestly increase, if it 
fail to moderate, the frequency of the discharges. The one which 
I have found to succeed best, consists of boiled milk with stale 
bread for breakfast and tea, and the tenderest meats, as very 
fine beef, mutton, chickens, or birds, with rice as the only vege- 
table, for dinner. If the child likes flour or rice pap, it may 
have either in place of the bread and milk. If it will take none 
of these, it may have milkwarm water and sugar, with bread ; 
or very delicate mush and milk, or milk toast. Should it refuse 
the dinner recommended above, we may substitute delicate soup, 
or some of the milk preparations. Between meals it ought to 
be allowed nothing but dry bread. All rich food, dessert, fruits, 
all vegetables except rice, candies and comfits, all kinds of cakes 
and hot bread, in fact, everything except the articles which I have 
mentioned or similar ones, ought to be rigidly, systematically, and 
perseveringly forbidden. Until this has been done for many days, 
or for several weeks, the disease has always, according to my ex- 
perience, obstinately persisted. 

I have already said that I have not found the ordinary remedies 
for simple diarrhoea to exert much effect upon the disease. On the 
contrary, the treatment for dyspepsia, that is to say, simple but nutri- 
tious diet, exercise, and the use of tonics and stimulants, have always 
removed it in a longer or shorter time. The tonics which I have 
employed are port wine, quinine, and iron. From a dessert to a 
tablespoonful of port wine was usually given in water three times 
a day, in connexion with iron. The preparations of iron used 
were Vallet's mass, of which from half a grain to a grain was 
given in pill three times a day ; or the solution of iodide of iron in 
the dose of first one, and then two drops, three times a day, in 
water, continued for one or two months. I have sometimes com- 
bined with each dose of the solution of iron, a drop of laudanum, 
especially if there were pain ; or the opiate might be given by in- 
jection every evening. The quinine was generally administered 
alone in the dose of a grain three times a day, for one, two, or 



TREATMENT. 243 

three weeks. It has not, however, proved so useful as port wine 
and iron. 

In a case attended with all the symptoms usually thought to 
indicate worms, the use of vvormseed oil was followed by the ex- 
pulsion of several very large lumbricoides. The child did not 
recover, however, for some weeks afterwards, and not until he 
had taken port wine and quinine for a considerable period. In 
other cases in which the verminous symptoms were also strongly 
marked, and in which the same remedy was given, no worms were 
expelled. 



SECTION II. 

DISEASES OP THE STOMACH AND INTESTINES, ATTENDED WITH 
APPRECIABLE ANATOMICAL LESIONS. 

ARTICLE I. 

GASTRITIS. 

General Remarks. — There are but two diseased states of the 
stomach attended with organic lesions, which demand our attention. 
These are inflammation and softening. The medical authorities 
of the day are divided on the question, whether these conditions 
ought to be regarded as distinct and separate diseases, or whether 
softening is not merely a secondary lesion, — the consequence of 
inflammation, or a cadaveric alteration. I shall consider both 
under the single head of gastritis or inflammation of the stomach, 
believing myself justified in so doing by the opinions of MM. Val- 
leix, Rilliet and Barthez, Bouchut, Dr. Carswell, and other writers. 
The former author [Guide da Med. Prat. t. v, p. 118) says, 
" It seems to me, therefore, impossible, in the present state of the 
science, to distinguish during life, the cases of simple pale soft- 
ening with thinning, from those in which softening is associated 
with evident traces of inflammation." At page 145 of the same 
volume, he says : "A description of the symptoms of pale soften- 
ing with thinning of the gastric mucous membrane might there- 
fore be drawn ; but as it would differ in no respect from that 
which I have already presented of chronic gastritis, it would be 
useless to reproduce it here, or, to speak in clearer terms, I be- 
lieve it results from the preceding discussion, that we ought to 
confound, in regard to the symptoms, this form of softening with 
chronic gastritis, of which it is generally a consequence, either 
pathological, or cadaveric." Rilliet and Barthez treat of the two 



GENERAL REMTARKS. 245 

conditions collectively, after stating (t. i, p. 453), that a care- 
ful study of their cases failed to show any important differences 
between the symptoms of inflammation and softening of the sto- 
mach. The same authors, in speaking of softening (Loc. cit.), 
say : " Our cases have in effect led us to regard this affection 
merely as a secondary lesion, and not as a primary disease influ- 
encing the whole organism, revealing itself by special symptoms, 
and pursuing a regular course." M. Bouchut [Loc. cit. p. 231) 
says : " Never, indeed, in young children, does softening of the 
stomach constitute an isolated disease ; what has been asserted of 
that alteration belongs in fact to entero-colitis, which we have just 
described." 

The authors of the Bib. du Med. Brat. (t. v, p. 600) are of 
opinion that it is doubtful whether softening ought to be regarded 
as a distinct and idiopathic disease or not, but that it is a patho- 
logical and not a cadaveric lesion, they think cannot be contested. 
Dr. Carswell {Cyclop. Brat. Med. vol. iv, p. 13 and 15), says it 
may occur either as a pathological or post-mortem lesion, and that 
the former is a consequence of inflammation. He states that when 
softening of the gastro-intestinal mucous membrane is a con- 
sequence of inflammation " the symptoms are those of gastritis or 
gastro-enteritis," and adds : " It need hardly be observed that there 
are no symptoms referable to the state of softening which we have 
described, considered in itself, and as a termination of inflamma- 
tion of the mucous membrane." M. Barrier {Mai. de VEnfance, 
t. ii, p. 118), says he cannot agree with those who regard softening 
of the gastro-intestinal mucous membrane as a specific disease. 
He considers it to be a simple lesion of tissue " generally produced 
after death, and which, when it commences during life, never ap- 
pears except as the consequence of an anterior morbid condition." 
He supposes both gelatiniform and pale softening to be the result 
either of a merely chemical action of the gastro-intestinal fluids 
" which may commence before death, but which is chiefly exerted 
in the interval between the fatal event and the autopsy ;" or to be 
a result of inflammation or of one of the diacrises (diseases of the 
secretory function^. 

21* 



246 GASTRITIS. 

Definition ; frequency. — By the term gastritis is meant inflam- 
mation of the mucous coat of the stomach. It appears by the con- 
sent of all, to be of rare occurrence as an idiopathic affection in 
children. M. Valleix (t. v, p. 80) says, " we must conclude, there- 
fore, that if gastritis occur in children, it is at least much more 
rare than in adults." The author refers, in the above quota- 
tion, to the idiopathic form of the disease, which he regards as of 
rare occurrence, while he states that the secondary form is very 
frequent. Rilliet and Barthez state (Loc. cit. p. 462), "that the 
lesions of the stomach are scarcely ever idiopathic." At page 
453, they assert that it ought not to occupy an important place in 
the nosology of infancy : " Primary, it is almost always a disease 
of slight severity ; secondary, it is but an epiphenomenon of dange- 
rous diseases, or the consequence of active medication ; lastly, 
often latent, it entirely escapes investigation." M. Bouchut says 
of the stomach [Loc. cit. p. 215), "This organ, which has been 
thought to play so great a part in the production of the diseases of 
children at the breast, does not at all deserve the attention be- 
stowed upon it." 

Causes. — The causes of gastritis and softening of the stomach 
are not well understood. The only ones which seem clearly 
ascertained, are the action of irritating substances, and particu- 
larly of active medical agents, introduced into the organ ; the 
predisposing influence of certain diseases ; and the solvent action 
of the gastric juice after death in the production of softening. 
Rilliet and Barthez state that, in their experience, one of the prin- 
cipal causes of gastric inflammation and softening was the appli- 
cation of energetic remedies to the gastro-intestinal mucous mem- 
brane, and particularly the use of tartar emetic potions continued 
for several days in succession. They also mention the use of 
kermes mineral and croton oil as having had the same effect. It 
is proper to state, moreover, that these effects almost always oc- 
curred when the disease for which the remedy was given was 
secondary, and very seldom when idiopathic. 

The diseases in the course of which gastritis and softening of the 
stomach are most apt to occur are : cerebral affections, especially 



CAUSES ANATOMICAL LESIONS. 247 

tubercular and simple meningitis, and apoplexy ; the eruptive 
fevers ; and inflammations of the thoracic and abdominal organs. 

Some observers go so far as to assert that the softening, which 
is generally confined to the mucous coat, but in some cases extends 
to the others also, is always the result of a cadaveric change. 
Thus, M. Bouchut is of opinion that " it is a consequence of the 
acidity of the fluids contained in the digestive tube of young chil- 
dren, which are exceedingly acescent in the disease to which we 
refer" (entero-colitis). M. Valleix concludes that in a certain 
number of cases there exist signs of inflammation which cannot be 
mistaken, and that this very inflammation may perhaps favour 
cadaveric softening in the parts attacked (t. v, p. 144). Rilliet 
and Barthez speak of inflammatory softening, but remark that 
in a large number of cases the alteration ought to be regarded 
as cadaveric. Dr. Condie (Dis. of Child, p. 186, 2d ed.) says, 
" we are still convinced, from the result of our own observations, 
that the gelatinous softening so frequently observed in children that 
have died of acute gastritis, is invariably the effect of intense in- 
flammation of the mucous and other tissues of the stomach." Dr. 
Carswell, as has already been stated, believes it to exist both as a 
consequence of inflammation and as a post-mortem change. 

I believe that the indigestions of children are not unfrequently 
followed by slight gastritis, as I have often met with cases which 
have been followed by fever, disposition to nausea or vomiting, 
anorexia, and loss of digestive power for several days. 

Age seems to exert but little influence on the production of gas- 
tritis, which occurs indifferently in very young and in older chil- 
dren, while softening is generally acknowledged to be much the 
most frequent in infants, and in children under six years of age. 

Anatomical lesions. — The pathological appearances in gastritis 
are redness, softening, thickening, ulceration and the presence of 
pseudo-membranes upon the mucous membrane. Writers describe 
different forms of gastritis, according: to the lesions found after death. 
The most important of these are the erythematic, pseudo-mem- 
branous, and ulcerative. The first of these, the erythematic, is cha- 
racterized by redness, softening, and thickening of the mucous mem- 



248 GASTRITIS. 

brane. The redness, which is one of the most important features, 
may exist in the form of vascular arborizations, ecchymoses, or 
uniform coloration of a rosy, deep-red, brownish-red, or purple tint. 
Softening is thought by Rilliet and Barthez to be almost as im- 
portant a sign of inflammation as redness, though they state that it 
may exist independently of inflammation. In most cases of erythe- 
matic gastritis, the softening is such that the mucous membrane may 
be removed with very slight force, and that it will yield no strips ; 
while in those which are very severe, the least scratch reduces 
the membrane to a pulp, and leaves the sub-mucous tissue ex- 
posed. When thickening is present it generally affects several 
neighbouring points simultaneously, which project somewhat above 
the healthy tissue, and give to the inner surface of the organ a 
rough and unequal appearance, quite different from its ordinary 
smoothness and polish. In some few cases the thickening im- 
plicates the sub-mucous coat also, which becomes fibrous and 
resisting. 

The pseudo-membranous form of gastritis presents little whitish 
portions of false membrane, which are smooth, polished, and of an 
irregular shape, or thin, soft, rough, of a more or less deep yellow 
colour, and which, isolated and distant from each other at first, 
become more abundant and extensive, and at last cover nearly the 
whole diameter of the organ. They are but slightly adherent to 
the mucous surface beneath. 

The ulcerative form of the disease is not a rare affection : it 
occurs in two varieties ; one in which the ulcerations affect the 
follicles of the stomach, and the other in which the mucous mem- 
brane itself is ulcerated. The pathological lesions of the former 
variety will be fully treated of in the article on entero-colitis, 
and I shall therefore confine my remarks entirely to the latter 
variety. The ulcerations of the mucous membrane are of a cir- 
cular or oval shape, or occur in winding lines of various lengths, 
and from a third of a line to a line in width. The circular and 
oval ulcerations are of various sizes, from the head of a pin to 
that of a small bean ; the smaller ones generally, but not always, 
affect the whole thickness of the mucous membrane, so that they 
rest on the sub-mucous tissue, while the larger implicate the sub- 



ANATOMICAL LESIONS. 249 

mucous tissue also, and therefore rest on the muscular coat. The 
edges of the winding ulcerations are usually soft and sometimes 
redder than the rest of the mucous membrane, whilst their depth 
is formed of sub-mucous tissue, and is of a grayish-white colour. 
At a more advanced stage, they increase both in length and 
breadth, unite after a time at their edges or extremities, and at last 
form extensive ulcerations, in the midst of which are seen small 
portions of softened and reddened mucous membrane. The ulcer- 
ations of this form do not extend to the sub-mucous tissue, which, 
on the contrary, is generally thickened. 

I have next to describe softening of the stomach, which has 
been erected into a special and distinct disease, and about the 
true nature of which there is very great discussion ; for while, as 
we have already seen, some observers assert that it is the result of 
acute inflammation, others ascribe it entirely to a post mortem 
chemical action of the fluids contained in the stomach, and others 
again to inflammation, or some lesion of the nerves of the or- 
gan. In regard to this vexed question, I can merely express an 
opinion formed from the study of some of the best authorities 
upon the subject. That a large number of the cases of softening 
depend on cadaveric change, will not, it seems to me, admit of 
doubt. That some are the consequences of inflammation, is, I 
think, equally clear ; whether the inflammation be the immediate 
cause, or, as M. Valleix surmises, merely predisposes the tissues 
of the stomach to be more readily acted upon by the fluids which 
it contains. Whether there be a third set of cases which should 
be regarded as forming a distinct disease, in which the softening 
depends on some peculiar unknown condition of the organ, inde- 
pendent, however, of inflammation or of a chemical action of the 
gastric juice, seems to me very doubtful, and certainly far from 
being proved in the present state of knowledge on the point. 

Dr. Carswell (Loc. cit. p. 14,) describes softening from in- 
flammation as presenting various degrees. It may be such that 
the mucous membrane breaks as soon as it is seized between the 
fingers and forceps ; in the second degree, the edge of a scalpel or 
the finger passed lightly over it, converts it into a soft, somewhat 
opaque, creamy-looking pulp ; in the third and last degree, a 



250 



GASTRITIS. 



stream of water a few inches in height carries it away. The 
softened portions may be quite pale, or they may present various 
shades of redness. The redness may be confined to the softened 
part, or extend to the neighbouring portions, and may vary from 
a slight rosy, bright, or dark red, to a purple or brown tint. In 
pale inflammatory softening, the colour may be pale gray, or 
yellow, very much like the natural tint, or paler than usual. 
Dr. Carswell does not believe that inflammatory softening extends 
from the mucous to the other coats of the organ, so as to pro- 
duce perforation. He states, on the contrary, that the kind of 
softening which occasions that accident depends on the chemical 
action of the gastric juice. 

Dr. Carswell describes the appearances of post-mortem softening. 
The softening is generally met with in the fundus of the organ; its 
degree varies between slight diminution of the consistence of the 
tissues, and that in which the mucous membrane resembles a 
quantity of albumen covering the sub-mucous coat ; the softened 
portion is generally very pale and transparent. The principal 
distinction between inflammatory and post-mortem softening, ac- 
cording to Carswell, is, that in the former the mucous membrane, 
" instead of being transparent, is more or less opaque, and even 
when it is completely disorganized, it resembles a mixture of flour 
and water or milk, rather than an albuminous or gelatinous fluid. 
Such is in fact, the principal character of inflammatory softening 
of the mucous membrane in whatever organ it occurs ; whereas 
the transparent gelatiniform softening is never observed except 
where the chemical agent is formed by which it is produced, viz., 
in the alimentary canal, and in some of the neighbouring organs, 
for the reasons which we have already given." 

The gelatiniform softening, which is that described by M. Cru- 
veilhier, as a disease peculiar to children, and which reduces the 
mucous membrane, and sometimes all the other tissues of the 
stomach, to the consistence of mucus or jelly nearly transparent 
in character, is, as we have just seen, supposed by Dr. Carswell 
to be invariably the result of post-mortem changes. MM. Rilliet 
and Barthez, on the contrary, (Loc. cit. t. i, p. 451,) while they 
state that this form of the lesion scarcely ever coincides with in- 



SYMPTOMS. 251 

flammation in the same patient, surmise that it may have followed 
inflammation, though at the time of death all appearances of the 
latter have perhaps disappeared. They add, however, that " it is 
probable that softening, particularly the gelatiniform, may com- 
mence as such, but of this we have no proof. 

Symptoms. — It is very difficult to draw an accurate picture of 
the symptoms of inflammation and softening of the stomach, for the 
following reasons : that they have not as yet been studied with a suf- 
ficient degree of care ; that they are, as was stated in the early por- 
tion of the article, seldom idiopathic, but almost always secondary 
affections in the course of other maladies ; that the symptoms 
which betray them resemble so closely those of intestinal diseases, 
as to make it very difficult, if not impossible, to draw a distinction 
between the two ; and lastly, that in the great majority of cases, 
gastric complaints coexist with intestinal lesions. 

The most important symptoms are vomiting, diarrhoea, loss of 
appetite, thirst, epigastric tenderness, sometimes tension of the ab- 
domen, and slight febrile reaction. 

Vomiting is the most important of the different symptoms of 
gastritis. It is not, however, according to Rilliet and Barthez, in- 
variably present. It was observed by them particularly in cases 
following the administration of active remedies, while in those 
which occurred spontaneously, it was much less common. It 
shows itself particularly after the taking of food or drink. Some- 
times when the stomach is empty, there is simply nausea and retch- 
ing. In severe cases the vomiting is frequent and accompanied 
by violent straining and pain. Diarrlioza exists in most cases, 
whether the attack be one of simple gastritis, or accompanied with 
enteritis. The appetite is generally lost or greatly diminished. 
Thirst is commonly acute, and often intense. The tongue is de- 
scribed by some writers as being generally red, and sometimes 
smooth and glazed. The authors above quoted, state, on the con- 
trary, that it presents nothing peculiar in most cases. It was 
generally moist, only slightly coloured, covered with a white or 
yellow coat of variable thickness, and in some rare instances, red 
on the edges and tip, or gluey, or even dry and harsh. As a 
general rule, the abdomen is normal, according to the same 



252 GASTRITIS. 

authors, though in some cases there is more or less swelling and 
tension. According to most writers there is generally tenderness 
on pressure in the epigastrium, and Dr. Condie mentions un- 
usual heat of the same region. Infants and young children are 
commonly restless and uneasy, as though in more or less pain, 
while those who are older complain of burning in the region of the 
stomach. It is well to remark that Rilliet and Barthez state that 
tenderness on pressure often exists, not at the epigastrium, but in 
one of the iliac fossae, or at the umbilicus, even when the stomach 
alone is inflamed. The condition of the circulation, and indeed 
all the symptoms, depend so much upon the nature of the con- 
comitant malady, that it is difficult to ascertain what are their 
real characters in simple gastritis. Most writers agree that fever 
usually accompanies the disease, and that it is commonly of the 
remittent type. It is certain, however, from other observations, 
that it does not always exist. 

In very violent cases there are added to the symptoms just de- 
scribed, those indicative of an adynamic state of the nervous sys- 
tem : — prostration, cool or cold skin, with perspiration ; weak, rapid 
pulse ; singultus ; sometimes convulsions, and death. 

Diagnosis and Prognosis. — The diagnosis must rest chiefly on 
the existence and frequency of vomiting; on the presence of epigas- 
tric pain or tenderness ; of swelling and tension of the abdomen ; 
excessive thirst ; and the absence of other disease which might 
account for the illness of the child. It is not possible in the pre- 
sent state of knowledge, to draw a distinction between inflamma- 
tion and softening, since, as we have seen, the symptoms of the 
two conditions are the same. 

The prognosis will depend on the severity of the gastric and 
constitutional symptoms, and of the concomitant disease, when 
the attack is secondary. When there is incessant and obstinate 
vomiting, so that not even water in small quantities can be re- 
tained after several hours of sickness ; when the tongue is red and 
glazed, or dry and brown ; when adynamic symptoms make their 
appearance, and emaciation makes rapid progress ; it is much to 
be feared that extensive softening has taken place, and that the 
case will prove fatal. 

Treatment. — The two most important points in the treatment 



TREATMENT. 253 

are the withdrawal of whatever may have produced, or may tend 
to keep up the disease, if they can be detected, and strict attention 
to diet. Whenever, therefore, the symptoms have made their 
appearance after the exhibition of powerful drugs, as tartar emetic, 
ipecacuanha, or cathartics, their use ought to be instantly sus- 
pended. The child should then be put on the strictest diet. If at 
the breast, it must be allowed to nurse only at rare intervals, and 
to take but little at a time. If fed on artificial diet, it should be 
restricted to barley or arrow-root water, or to very weak milk and 
water. Nothing solid, and no rich liquid nourishment ought to be 
allowed, unless the child is in a state of weakness and debility 
from previous or concomitant disease, such as to make it abso- 
lutely necessary to endeavour to maintain its strength. Billard 
even recommends that the child be sustained by means of nutritive 
enemata, consisting of farinaceous substances, whilst the digestive 
function is allowed a total rest. 

Antiphlogistics are useful and proper when the disease occurs 
in a strong and healthy child, when associated with fever, and 
when there is nothing in the nature of the accompanying disease, 
if it be a secondary case, to prevent their employment. The most 
suitable mode of depletion is by leeches, which should be applied 
to the epigastrium. It is best to take but a very moderate quantity 
of blood, for fear of exhausting the patient. After the use of the 
antiphlogistic remedy, a warm bath will be found of great service 
in moderating the heat of the skin, and rendering the child more 
comfortable. Small pieces of ice ought to be put into the mouth 
occasionally, as a refrigerant, or small quantities of iced drinks 
may be allowed from time to time. As soon as the bleeding from 
the leech-bites, if leeches have been employed, has ceased, a warm 
light mush poultice to the epigastrium, is a valuable and useful 
remedy. Some writers recommend the use of blisters to the epi- 
gastrium. I should much prefer the warm poultice or the occa- 
sional application of a mustard poultice. Dr. Condie recommends 
small doses of calomel, from a quarter to half a grain every one 
or two hours. Opiates are useful in allaying nausea and vomit- 
ing, and appear to exert a favourable influence on the progress 
of the disease. 

22 



254 ENTERO-COLITIS. 

When vomiting is frequent and troublesome, it may generally be 
allayed by the administration of lime water and milk, given in tea- 
spoonful quantities, every fifteen minutes or half hour ; by observing 
the precaution of allowing the food and drink to be given only in 
the smallest quantities (teaspoonful to a tablespoonful), and at con- 
siderable intervals ; by the application of warm cataplasms over 
the abdomen, or a spice plaster to the epigastrium ; or, lastly, 
by the exhibition of a few drops of laudanum, or paregoric, to be 
repeated if necessary. If the child becomes weak and exhausted, 
with coolness and abundant moisture upon the limbs, we must resort 
to the administration of some kind of stimulant. The best are pro- 
bably weak brandy and water, given in very small quantities, 
wine whey, or milk punch ; or we may employ the aromatic spirits 
of hartshorn. 



ARTICLE II. 

ENTERO-COLITIS. 

General Remarks. — In treating of inflammation of the in- 
testinal tube, I shall combine under one article inflammation of 
the large and small intestine, inasmuch as it appears from the re- 
searches of different observers that they coincide in the majority 
of cases. It would seem from the statements of Billard, that it is 
not unusual to meet with enteritis alone in the first year of life, 
for of 80 cases of inflammation of the intestinal tube, during that 
age, carefully observed by him, there were 36 of enteritis ; 30 of 
entero-colitis : and 1 4 only of colitis. Bouchut, on the contrary, 
(Loc. cit. p. 210,) says that entero-colitis is almost peculiar to 
young infants. He adds that the principal morbid alterations of 
the disease are found in the large intestine, and, by extension, in 
the termination of the small intestine. Rilliet and Barthez, whose 
observations apply to older children (over 15 months), say: "En- 
teritis by itself is rare ; it often coincides, on the contrary, with 
colitis : colitis without enteritis is very frequent." (T. i, p. 487.) 
M. Legendre, (Bibliotheque du Med. Prat. t. v, p. 649,) found the 



GENERAL REMARKS. 255 

large intestine alone diseased in 9 of 28 cases of diarrhoea, while 
of the alterations of the small intestine he says, (p. 652,) "Never 
isolated, but always united with similar lesions of the large intes- 
tine, these alterations are, in general, less serious than those found 
in the latter portion of the digestive tube." 

Another motive for describing the diseases of the whole intes- 
tinal tube under one head, is the difficulty, not to say impossibility, 
of recognising during life the affections of its different portions. 
Billard (p. 428), recognises this difficulty, for he says : " In con- 
sequence of the impossibility we have found to exist of tracing 
with exactitude the series of symptoms proper to inflammation 
of the different portions of the digestive tube, we shall con- 
tent ourselves with presenting an analytical sketch of the causes, 
symptoms, and ordinary course of inflammation of the mucous 
membrane of the intestines in general." Rilliet and Barthez, and 
M. Bouchut, also describe enteritis and colitis together, under the 
title of entero-colitis. 

Writers make several divisions or forms of disease of the intes- 
tinal mucous membrane. Of these, the most important are the 
erythematous, pseudo-mernbranous, and follicular inflammations, 
softening, and gangrene. The whole subject is involved in much 
obscurity, in consequence of the variety of the lesions, and the 
different views as to their nature, which have been adopted by 
different authors. The follicular form of disease particularly, has 
given rise to a great deal of discussion, some asserting that it is 
not an inflammation, but a simple functional derangement of the 
secretory apparatus of the bowel, while others as strenuously main- 
tain its inflammatory nature. In the present article, I shall, under 
the title of entero-colitis, devote particular attention to the erythe- 
matous and follicular forms of inflammation, and to softening of 
the mucous coat of the bowels : the pseudo-membranous form of 
inflammation and gangrene are rarely met with, and are therefore 
of much less importance. 

Definition ; symptoms ; frequency ; forms. — By the term en- 
tero-colitis is meant inflammation with its attendant lesions, ulce- 
ration, softening, thickening, pseudo-membranous exudations and 
gangrene of the intestinal mucous membrane. 



256 ENTERO-COLITIS. 

Under this title I shall describe the different kinds of diarrhoea 
treated of by Underwood, Eberle, and Dewees, under the titles of 
bilious, mucous, and chronic diarrhoea, and by Dr. John Cheyne, 
{Essays on Dis. of Children. Edinburgh, 1801-2,) under that of 
Atrophia Ablactatorum or Weaning-brash. 

Entero-colitis is one of the most frequent of children's diseases. 
It appears from a table published by Dr. Condie, (Dis. of Child. 
note, p. 89,) that in the ten years preceding 1845, there were 6068 
deaths in Philadelphia under fifteen years of age, from diseases of 
the digestive organs ; of this number 4786 were from diarrhoea, 
dysentery, cholera infantum, and inflammation of the stomach and 
intestines, and as entero-colitis exists in by far the greater part 
of these diseases, we may understand how extremely frequent 
an affection it is. The deaths from affections of the digestive 
organs during the period referred to, constituted about a fourth 
of the whole mortality under fifteen years of age ; whilst those 
from diseases of the brain are stated to have been rather more than 
a fourth, and from diseases of the respiratory organs nearly a 
seventh. It appears, indeed, that entero-colitis, in the form of 
diarrhoea, dysentery, cholera infantum, or what is called in the 
bills of mortality, inflammation of the stomach and intestines, is 
by far the most fatal disease of childhood. We may appreciate 
yet more accurately the importance and frequency of the disease, 
by reference to the statements of Rilliet and Barthez, who say (t. i, 
p. 483,) that, taking into consideration all the cases they observed, 
including tubercular cases, they find that of every two children 
that die, one presents a more or less serious lesion of the large in- 
testine. They add : " if it be recollected that this holds true par- 
ticularly in regard to younger children, it will be seen that it is 
rare for a child to die between two and five years of age, without 
having either colitis or softening of the large intestine." Bouchut 
states that entero-colitis is one of the most dangerous affections of 
children at the breast ; " It is the most common of all those inci- 
dent to that age." (p. 210.) 

I shall describe two forms of the disease, the acute and chronic. 
The acute form is accompanied by active and inflammatory symp- 
toms from the first, and runs its course in a few days or weeks ; 



FREQUENCY FORMS CAUSES. 257 

the chronic form is unaccompanied by acute symptoms, and lasts 
several weeks or months. 

Causes. — The most frequent cause of enteritis in children, the 
one most clearly and positively ascertained, is, it seems to me, 
improper alimentation. This may consist either of an unhealthy 
milk of the nurse, or, what is much more common, improper arti- 
ficial nutriment. The kind of food most apt to produce the effect 
is one composed exclusively or in considerable proportion of some 
of the feculent substances, which constitute so large a portion 
of the diet of children throughout the civilized world. To prove 
the truth of this assertion it is only necessary to quote the opi- 
nions of those who have most carefully studied the subject. M. 
Valleix [Guide du Med. Prat. t. iv, p. 60, 61, and Bulletin 
Gen. de T/ierap.> article Acute Enteritis of Adults and new-born 
Children, March, 1845) clearly asserts that the most frequent 
cause of muguet, which he believes to be essentially connected 
with enteritis, is a too exclusively feculent alimentation. In the 
article last cited, while speaking of the great importance of this 
cause, he says : " What proves that my assertion is not hypo- 
thetical is, first, that all the deaths from enteritis in children that 
I have seen, occurred in those who had been placed upon this 
kind of regimen, and second, that the disease did not occur in 
any of those observed by me in private practice for whom I had 
directed an exclusively milk diet up to four, five, or six months of 
age." He adds that M. Trousseau has arrived at similar opinions, 
after studying the same diseases at the Necker Hospital ; and that he, 
on account of the danger of a system of diet disproportioned to the 
digestive powers, recommends that children should be confined 
almost exclusively to the breast until after the first dentition is 
completed. Barrier, speaking of the follicular diacrisis (Loc. cit. 
t. ii, p. 40), states that the artificial food given to children at the 
period of weaning is a frequent cause of the affection, and that of 
all the different kinds of food habitually employed at that period, 
feculent substances are the most injurious. I have, myself, fre- 
quently known entero-colitis to follow the employment of artifi- 
cial diet either alone, at the period of weaning, or in children 
who were partly nursed. Children fed wholly on artificial diet 

22* 



258 ENTERO-COLITIS. 

from birth, rarely escape according to my experience attacks of the 
disease, which in many prove fatal. I have, on several occasions, 
seen children recover rapidly from the disease, after suffering more 
or less for weeks, by the suspension of a diet consisting wholly or in 
too large proportion of farinaceous materials, and the substitution of 
one of milk and cream, prepared with gelatine, and containing a 
very small quantity of arrow-root, rice, or wheat flour. (See article 
on thrush, page 193.) It is not merely the quality, but the quantity 
also of artificial food that proves injurious to infants. Over-feeding 
has always been recognised as a fruitful source of bowel complaints 
in early life. Another cause is the preparation of the food in too 
thick and rich a manner, thereby overtasking the stomach, intended 
during the early months to receive only the thin milk supplied by 
nature. The custom, therefore, of feeding infants on thick oatmeal 
gruel, with but little or no milk, on what is called cracker victuals 
(pounded crackers with water and sugar, or milk), on thick bread 
and milk, on preparations of rice of too solid a nature, or indeed, 
on any kind of diet not consisting chiefly of milk, and in which 
feculent substances enter merely as secondary constituents, may 
safely be asserted to be the most frequent cause of the disease un- 
der consideration. 

An unhealthy character of the milk of the nurse is also known 
to be a cause both of simple diarrhoea and entero-colitis. When 
the granules which exist as a physiological element in the colos- 
trum secreted during the first few days after childbirth, continue to 
be secreted after that period, the infant is almost certain to suffer 
from entero-colitis, and not unfrequently to perish, unless weaned 
or transferred to another nurse. It is said, also, that when the 
mammary secretion is acid, instead of alkaline, when it contains 
mucus or pus globules, when the nurse is liable to vivid moral 
emotions of any kind, or when addicted to intemperance, the child 
is very apt to suffer either from the disease under consideration, or 
from simple diarrhoea. 

After the causes just enumerated, the one which appears to ex- 
ert the strongest influence is dentition. That the evolution of the 
teeth, though a physiological process, is a powerful predisposing 
cause of diarrhoea and enteritis, there cannot, it seems to me, re- 



causes. 259 

main a doubt at the present time. It is one recognised by many 
of the most able writers and observers of the day, and by most 
practitioners. Rilliet and Barthez agree with Trousseau in the 
opinion that the simple diarrhoea so apt to occur in children at the 
epoch of the first dentition, is often the origin of chronic intestinal 
lesions which finally reduce them to extreme debility and emacia- 
tion. They say that careful investigation will generally show that 
nearly all the cases of inflammation and softening date either from 
the epoch of dentition, from the period of weaning, or from the 
time at which some considerable change in the character of the 
regimen was made. M. Bouchut states that of 110 children in 
whom the first dentition was going on, 26 escaped any indisposi- 
tion, 38 suffered from restlessness, colics, and occasional diarrhoea, 
so mild as to excite no alarm in the parents, whilst 46 had abun- 
dant diarrhoea. In 19 of the last series it appeared coincidently 
with the fluxion of the gums, occurring at the time of emergence 
of each tooth, and disappearing entirely in the intervals ; in the 
remaining 28, in all of which the process of dentition was difficult, 
the diarrhoea persisted and gradually assumed the characters of 
entero-colitis. M. Legendre and M. Barrier (Loc. cit.) both agree 
in ascribing very great effect to the influence of dentition in the 
production of diarrhoea and entero-colitis. The former asserts the 
diseases referred to to be much the most frequent between the ages 
of six or seven months, and two or two and a half years, which 
includes exactly the period occupied in the first dentition, while 
they are only met with exceptionally after three years of age. 

The act of weaning is very apt to result in the production either 
of simple diarrhoea or entero-colitis, in consequence, no doubt, of 
the irritation set up in the gastro-intestinal surface, by the change 
of food made at the time. The diarrhoea which occurs at this 
period was formerly, and is still, not unfrequently, called weaning- 
brash. Dr. Stokes [Cyclop, of Med. Art. Enteritis) says of this 
disease that it " is manifestly an acute enteritis, produced by the 
change of food, and in which nature seeks to relieve the inflamma- 
tion by a super-secretion." 

We may conclude, therefore, in the words of Rilliet and Barthez 
(Loc. cit. p. 541), "that the greater number of cases of entero- 



260 ENTERO-COLITIS. 

colitis in young children are caused by dentition, weaning, and any 
very sudden change of regimen or other hygienic conditions." 

Various other causes are cited by writers. Amongst the most 
important are excessive heat at certain seasons ; unfavourable 
hygienic conditions as to habitation, ventilation, clothing, cleanli- 
ness, and want of exposure to the air ; the existence of certain dis- 
eases ; and a lymphatic constitution, or one debilitated and exhaust- 
ed by any cause. 

That heat of weather acts as a predisposing cause to entero- 
colitis and diarrhoea, is clearly shown by the fact of the much 
greater prevalence of these diseases, and particularly of cholera 
infantum or summer complaint, during the three summer months. 
M. Valleix has shown, also, that the acute enteritis of new-born chil- 
dren is much more prevalent during the warm, than the cold season 
of the year. 

It is scarcely necessary to do more than state the fact that the 
unfavourable hygienic conditions above referred to, act as predis- 
posing causes to the disease. This is clearly shown to be true by 
the evidence of many writers, and by the very extensive prevalence 
and great fatality of the affection in hospitals, and amongst the 
children of the destitute classes of society in cities and towns. 

Entero-cohtis is prone to occur as a secondary affection in many 
of the acute diseases of children. It is by far the most common 
in the course of the eruptive fevers, particularly measles, and in 
that of typhoid fever. It is also a frequent complication in the 
latter stages of pneumonia. 

That children of feeble constitution and lymphatic temperament 
are more disposed to the disease than others, is, I think, sufficiently 
proved by the evidence of various observers. Lastly, that the in- 
cautious and excessive use of perturbing systems of medication, 
addressed to the digestive tube, often occasions diarrhoea and entero- 
colitis, is, it seems to me, fully shown by the researches of Riiliet 
and Barthez, and by my personal experience. 

Anatomical lesions. — It has already been stated that the altera- 
tions of the large intestine are, as a rule, much more frequent and se- 
rious than those of the small intestine. It appears from the researches 
of MM. Riiliet and Barthez, and Legendre, that enteritis rarely ex- 



CAUSES ANATOMICAL LESIONS. 261 

ists alone, whilst colitis, by itself, or combined with enteritis, is 
quite frequent. M. Legendre states that inflammation of the small 
intestines never occurs without corresponding lesions of the large 
bowel, while in 28 cases of diarrhoea, he found the large intestine 
alone diseased in 9. From a table of different intestinal lesions, 
given by Rilliet and Barthez (Loc. cit. t. i, p. 488), it appears that 
they have met with 45 cases of erythematous, pseudo-membranous, 
ulcerative or pustular enteritis; with 113 of the same forms of 
colitis; with 90 of follicular enteritis; 64 of follicular colitis; and 
with 28 of softening of the small, and 35 of softening of the large 
intestine. It seems clearly established, therefore, that inflamma- 
tion of the large is considerably more frequent than that of the 
small intestine, and much more apt to exist alone. 

It has already been stated that my remarks would be confined 
chiefly to the erythematous and follicular forms of inflammation, 
and to softening of the intestines. But even here we are met 
by a difficulty, since some writers confound the two forms of in- 
flammation together, and regard them merely as different degrees 
of the same alteration. Such is the view taken by the English 
authors that I have consulted, and by MM. Legendre and Bouchut. 
Rilliet and Barthez, on the contrary, describe the anatomical lesions 
of the two forms separately, with great care, but confound them 
together in their description of the symptoms. Barrier, as we 
have already seen, makes of the follicular form a disease altogether 
different from ordinary inflammation, and calls it follicular diacrisis. 
For my own part, I am strongly disposed to believe that erythema- 
tous and follicular inflammation, and softening of the intestinal mu- 
cous membrane, are indeed, as asserted by Legendre and Bouchut, 
and by some English writers, merely different degrees of the same 
disease. That they very often coincide in the same individual is 
proved by the observations of different authors, and particularly 
by those of Rilliet and Barthez, who have given a table of 185 
autopsies (t. i, p. 488), showing the exact manner in which they 
are united in the same individual. From this table it appears that 
of the whole number, there were only 2 cases of enteritis, 32 of 
colitis, 11 of entero-colitis, 12 of follicular enteritis, 3 of follicular 
colitis, and 13 of follicular entero-colitis, existing each alone, un- 



262 ENTERO-COLITIS. 

combined with other lesions ; there were also 18 cases of softening 
of the small or large intestine without other alterations ; while the 
remaining cases, 97 in number, consisted of the different lesions 
enumerated, variously combined in the same individual. 

Inasmuch, however, as the relation of the two forms to each 
other is not as yet fully determined, and as a separate description 
will be more accurate than one in which the two are mingled 
together, I shall adopt the former plan, stating, however, the fact 
which is acknowledged by all, though variously interpreted, that 
they very often co-exist in the same individual. 

Erythematous inflammation is generally slight, both in degree 
and extent, in the small intestine. In some few cases it is general, 
and then appears in the form of redness produced by arborizations. 
In other instances it appears in spots of more or less vivid in- 
flammation, which may extend throughout the small intestine, or 
be limited to certain portions. Though sometimes confined to the 
upper part of the bowel, constituting duodenitis, it is much more 
apt to exist in the lower part of the ileum, where it generally as- 
sumes more serious characters than above. At the latter point it 
appears in the form of more or less bright injection with tumefac- 
tion and sometimes softening of the mucous membrane. 

The large intestine is generally contracted and lessened in size, 
according to Bouchut. This condition is mentioned also by Dr. 
Cheyne, in his remarks on atrophia ablactatorum, {hoc. cit.,) and 
by Dr. Eberle as existing in a case examined by himself, (Loc. cit. 
p. 239,) in which he found the whole length of the colon contracted 
to a size that scarcely admitted the little finger. The erythema- 
tous inflammation generally presents itself in the shape of arboriza- 
tions or spots, and seldom of bands. The inflammation is generally 
most acute in the cascum, descending colon, and rectum, particu- 
larly the latter, where it often assumes great severity. The colour 
of the mucous membrane varies from a pale rosy to a deep scarlet 
tint, which is either uniform, and depends on minute injection of 
the capillaries, or in some cases affects only the summits of the 
folds of the mucous tissue. The mucous membrane is often 
thickened, and still more frequently softened. Of the latter altera- 
tion, however, I shall speak after a time; while of ulceration, which 



ANATOMICAL LESIONS. 263 

is still more common, notice will be taken under the head of the 
follicular form of the disease. 

Follicular inflammation. — The follicular apparatus of the in- 
testinal tube, consists of isolated and agminated glands. The 
isolated follicles are abundant in the stomach, and exist through- 
out the length of the intestinal tract. They are most abundant in 
the superior and inferior portions of the small intestine, less so in 
the middle, and numerous again in the large intestine, particularly 
the rectum. The agminated follicles, as is well known, are found 
chiefly in the ileum along the free edge of the intestine, and become 
more and more numerous as we approach the caecum. The isolated 
follicles are not very distinct in their normal condition, but un- 
dergo various changes when affected with disease. M. Gendrin 
( Trait. Philosophique de la Med. Prat. t. iii, p. 6,) says that they 
are scarcely so large in their normal condition as the head of a 
small pin, and that they consist of little white bodies, upon which 
we can rarely distinguish with the naked eye, but always with a 
lens, a grayish point, which is the excretory orifice. He distin- 
guishes the crypts into simple and compound. The simple have 
just been described ; the compound are formed of an agglomera- 
tion of several simple crypts or cryptiform granulations, having a 
common reservoir and excretory canal. It must be observed that 
he does not mean by the compound crypts, the glands of Peyer, 
which he elsewhere describes under the title of cryptous plaques. 
He states that the simple crypts are found in the stomach, espe- 
cially the pyloric half and along the great curvature, in the duo- 
denum, and in the jejunum, in such quantities that they seem to 
be almost confluent. As we descend into the ileum they become 
larger and less frequent. They are rare in the large intestine, 
where instead of them are found the compound crypts, which are 
there very numerous. The latter exist also in the stomach and 
duodenum, but are rare in the small intestine. 

The alterations of the follicular apparatus of the gastro-intestinal 
mucous membrane, constituting the follicular inflammation of 
several writers, may be referred to two heads, first, increased de- 
velopment without apparent inflammation, and second, inflamma- 
tion, with or without disorganization. 



264 ENTERO-COLITIS. 

The first condition, or that of increased development without 
evident inflammation, presents the following characters. The 
isolated glands have become enlarged, and seem therefore more 
numerous than in the healthy condition ; they appear in the form 
of lenticular grains seated in the texture of the mucous membrane, 
sometimes projecting from its surface, sometimes not, and in other 
instances appearing to be situated beneath it ; the excretory orifices 
of the glands are often enlarged and tumid, and easily distinguished 
under the form of a grayish or blackish point in the middle of the 
gland ; in other cases the orifices cannot be distinguished until 
slight pressure is made upon the crypts, when a drop of mucus 
may be seen exuding through the open point. The colour of the 
follicles in this condition is dull white, rosy, or yellowish ; they 
are generally from a third to two thirds of a line in diameter. Dr. 
Horner, (Am. Journ. Med. Sc. Feb. 1829,) speaks of them in 
this state of development as resembling " small grains of white sand 
sprinkled over the mucous membrane, and about the size of a 
millet seed." 

The agminated glands or plaques of Peyer are found in the same 
state of increased development. They are tumefied ; project above 
the level of the surrounding mucous membrane, and are evidently 
enlarged, without, however, always presenting evidences of inflam- 
mation. 

M. Barrier describes another condition of the follicles, which is 
met with chiefly in the large intestine. This is an enlargement of 
the orifice of the gland, which will easily receive a small probe, 
and sometimes measures near half a line in diameter. This dilated 
orifice, which might readily be mistaken for an ulceration, leads 
into a little cavity, which is the follicular sac itself. 

Authors are very much divided as to whether the alterations of 
the follicles just described ought to be regarded as the result of in- 
flammatory action or not. Billard says it is not of " evident in- 
flammatory nature ;" and in another place, that he does not con- 
sider it a " frank inflammation of the muciparous follicles," but as 
" a degree intermediate between the normal and inflammatory state." 
M. Barrier, on the contrary, says that these alterations are evi- 
dently not of an inflammatory nature, and that they do not entitle 



ANATOMIC All LESIONS. 265 

the disease to the name of gastro-enteritis or colitis. He, therefore, 
follows M. Gendrin, and expresses the condition in which they 
occur, by the word diacrises, or altered secretions. Rilliet and 
Barthez believe the alteration to depend upon inflammatory action, 
without, however, affirming it positively. The authors of the 
Biblotheque du Medecin Praticien, (t. v, p. 657,) state that it 
cannot be doubted that inflammation plays some part in the ana- 
tomical alterations of the secretory apparatus of the digestive tube 
just described, and those we shall speak of directly. For my own 
part, I am clearly of opinion that they are in all probability the 
first stage of inflammation ; for, as we shall presently see, when 
the condition persists for some length of time, the follicles almost 
invariably become ulcerated and surrounded by patches of inflam- 
mation, and though it is possible, as M. Legendre supposes, that 
the surrounding inflammation may be the result of ulceration of 
the crypts, it is difficult to understand how that ulceration could 
occur independently of inflammation. 

The other changes we have to notice are evident inflammation 
and ulceration of the follicles. M. Legendre (Biblioth. du Med. 
Prat. t. v, p. 650) says that after the morbid development of the 
follicles, (which he calls the first degree or stage of disease,) has 
existed for some time, if the causes which produced it continue in 
action, the alteration becomes the point of departure of numerous 
ulcerations, which are deeper in proportion to their time of dura- 
tion. The researches of the French observers prove that the 
alterations, and particularly the ulcerations of the follicles are more 
frequent and to a greater extent, in the large than in the small in- 
testine. M. Legendre states that in 28 cases of diarrhoea, he 
found the large intestine alone diseased in 9 ; while of the small 
intestine he says, that the morbid modifications of its follicular 
apparatus never occurred alone, but were always combined with 
similar lesions of the large bowel, and, moreover, were generally 
less considerable than those of the latter : from these circumstances 
he is led to infer that in chronic diarrhoeas, the small intestine is 
last attacked. A reference to the dissections of Dr. Horner, and 
especially to those of Dr. Hallowell, (Am. Journ. Med. Sc., July, 

23 



266 ENTERO-COLITIS. 

1847,) will show that these statements as to the seat of the fol- 
licular lesions hold good also in regard to cholera infantum. 

I shall first describe the ulcerations as observed in the large in- 
testine. In the forming stage they appear in the form of superficial, 
circular erosions, from one to two thirds of a line in diameter, 
generally neither injected nor protuberant. In this stage they may 
easily escape observation, under superficial examination. Each 
of these ulcerations will be found developed upon a follicle. When 
more advanced, the mucous membrane is seen to be riddled, not 
with superficial erosions, but with true ulcerations, of a perfectly 
circular shape, affecting the whole thickness of the membrane ; 
their edges, either pale or injected, circumscribe a small, grayish, 
semi-transparent corpuscle, of the size of the head of a pin, from 
which by pressure a drop of opaque, grayish mucus may be made 
to escape. In a still more advanced stage may be observed, some- 
times in the last half of the intestine, but most frequently in the 
rectum only, deeper and larger ulcerations, which, when isolated, 
are perfectly circular, and measure from a line to a line and a 
half in diameter, but which, from the running together of two 
ulcerations, are sometimes irregular in shape, and of a larger size. 
The bottom of these ulcerations is formed of the sub-mucous, 
and often of the muscular tissue ; their edges are of a slate-gray 
colour, thickened, and sometimes detached ; their depth is occa- 
sionally covered with a pultaceous, apparently pseudo-membranous 
layer, of a grayish-white colour. That the large and deep ulcera- 
tions just described, even when most extensive, are originally 
seated in the muciparous crypts, is proved by the presence amongst 
them of other ulcerations of more recent date, and smaller size, 
which present in their centres a well-marked mucous follicle, 
and show clearly the origin of the larger and more advanced 
ulcerations. 

The mucous membrane itself presents different appearances ac- 
cording to the date and degree of the ulcerations. When the superficial 
erosions alone are present, it sometimes retains its ordinary normal 
grayish tint, but, more generally, is of a rose-gray colour, dotted 
with little patches of a deeper red, produced by very fine arboriza- 
tions; or, lastly, it presents a very minute red punctuation. Be- 



ANATOMICAL LESIOjVS. 267 

sides the injection, there are usually softening and thickening of the 
membrane. The redness, softening, and thickening, are all most 
considerable around the deep ulcerations above described. 

Small Intesti?ie. — The lesions of the follicles of the small in- 
testine are generally much less considerable than those of the 
large. Simple morbid development of the isolated and agminated 
follicles are almost the only alterations that are found. The fol- 
licles, especially the agminated, often have the appearance of 
being ulcerated, but a careful examination will generally show that 
this is not the case. The appearance depends on the fact of the 
orifices of the glands being dilated, upon unequal tumefaction 
of the surrounding mucous membrane, and upon the presence in 
the plaque of small, irregular, grayish points, consisting of a pul- 
taceous matter, which makes the plaque look more projecting than 
usual. If, however, the pultaceous layer be gently rubbed with a 
piece of linen, it can be easily detached, upon which the mucous 
membrane beneath is found red, softened, and thickened, but not 
ulcerated. The lining membrane of the small intestine seldom 
presents any important changes in follicular disease. It usually 
retains its natural colour, consistence, and thickness. When, 
however, the crypts are much altered, it is generally red, softened, 
and thickened. 

Softening of the mucous coat is very generally present to a 
greater or less degree in entero-colitis. Bouchut states that in young 
infants the last eight or ten inches of the ileum are the portion of 
the small intestine generally diseased. The softening is sometimes 
accompanied by inflammation and thickening. In two cases he 
found the mucous membrane white and opaque, with an entire 
destruction of its consistence from the pylorus to the ileo-csecal 
valve. In the large intestine its consistence is rapidly modified, 
so that it is generally impossible to obtain strips. He adds that 
this condition always coincided with vivid redness. Legendrc says 
that the mucous membrane of the small intestine is not softened 
unless the alterations of the muciparous crypts are very marked 
and extensive. In the large intestine he found the mucous tissue 
slightly softened around ulcerations of recent origin and slight 
extent, while around those of greater depth, the softening existed 



268 ENTERO-COLITIS. 

in a much more advanced degree. Rilliet and Barthez, whose ob- 
servations were made in children over fifteen months old, describe 
both pale and gelatiniform softening as frequently occurring in the 
small intestine. They say that it generally occupies the whole 
extent of the mucous membrane from the duodenum to the ileo- 
csecal valve, that it is rarely limited Jo the inferior, and still more 
rarely to the superior portion of the bowel. Both varieties are 
common also, in the large intestine, and more frequently affect the 
whole than only a part of that bowel, though sometimes limited to 
the caecum, colon, or rectum. 

Symptoms ; duration. — In infants the acute form of entero- 
colitis generally begins with restlessness and fretfulness. The 
mother observes that the child sleeps less than usual, and for 
shorter periods, and that its sleep is uneasy and broken by sighing 
or moaning, or by occasional expressions of pain flitting across 
the face. It takes the breast less frequently, and is satisfied to 
nurse for a shorter time, showing thereby an evident diminution of 
appetite. At the same time it is apt to reject the milk which it has 
taken in larger quantities than usual, and this is often observed to 
have a very acid smell. After these symptoms have lasted a few 
days, and sometimes without them, the peculiar symptoms of the 
disease, the diarrhoea and other abdominal symptoms, make their 
appearance, and are accompanied by febrile reaction in most 
cases. 

In older children the acute form may come on suddenly, with 
diarrhoea, loss of appetite, thirst, sometimes vomiting, abdominal 
pain and fever, from the first ; or., as happens very frequently, the 
case begins with slight diarrhoea, unaccompanied by fever, or 
other signs of sickness, and it is not until after several, or eight, 
ten, or even more days, that signs of inflammation make their ap- 
pearance. 

After the disease is established, the most important symptoms 
are the following. The diarrhcea, which is the most prominent and 
characteristic, presents various characters. In order to appreciate 
this symptom as its importance requires, the practitioner ought 
always to see the napkins of the child at least once, and often more 
frequently, in the day. It exists in almost all cases of entero-colitis, 



SYMPTOMS. 269 

in the erythematous and follicular inflammations, and in the ulcer- 
ations and softening which accompany or succeed simple inflam- 
mation. It is seldom absent, and yet that it is so sometimes, is 
proved by the facts mentioned by Rilliet and Barthez, who state 
that they have calculated, from their cases, that it is wanting in 
about one of every tw r elve cases of inflammation or softening of the 
intestine. They add, however, that it is absent only in slight 
attacks, and is always present when the disease is severe. It 
varies greatly as to the frequency, abundance, and characters of 
the stools. It varies also in its mode of progress, so that it pre- 
sents great differences as to all these points from day to day, and 
at different portions of the same day. We may remark in general, 
however, that in proportion to the severity of the inflammation, so 
is the diarrhoea violent and constant, and that it usually increases 
as the signs of inflammation become more and more marked. It 
is rare to have severe diarrhoea when the anatomical lesion is of 
slight extent, though this does sometimes happen. The number 
of the stools, as has been stated, is exceedingly variable. This 
depends in great measure upon the violence of the case ; for while 
in those which present the symptoms of an inflammation of small 
extent, the stools seldom amount to more than six or eight a day, 
in those in which the evidences of more extensive and severer in- 
flammation are present, there will be fifteen, twenty, twenty-five or 
even more per diem. The consistence of the stools may vary be- 
tween that which characterizes them in a state of health, and that 
of the thinnest serous fluid. The 'materials of which they are 
composed consist chiefly of mucus, bile, serum, small portions of 
feculent matter, portions of undigested caseum or other food, and 
blood. M. Bouchut (Loc. cit. p. 219), describes those of very 
young children as presenting the following characters. 

1. They are semifluid, homogeneous, greenish, and similar to 
cooked vegetables ; neutral. 

2. Semi-fluid, homogeneous and green ; often acid. 

3. Semi-fluid, heterogeneous, greenish, and mixed with yellowish 
fragments of ordinary faeces; neutral. 

4. Semi-fluid, heterogeneous, greenish, and mixed with fragments 
of undigested caseum ; acid. 

23* 



270 ENTERO-COLITIS. 

5. Diffluent, greenish, heterogeneous, composed of a large quan- 
tity of water in which float yellowish and greenish, or whitish par- 
ticles ; acid. 

6. Diffluent, greenish, like the preceding, and mixed with gas of 
a mawkish and sometimes sourish smell. 

7. Diffluent, completely serous. 

8. Bloody stools are very rare at this age. We have met with 
them once only in a child affected with acute hepatitis. 

Such are the appearances of the stools in children who have not 
completed the first dentition. After the epoch of the first dentition 
the disease becomes much more rare, and when it occurs, is gene- 
rally of a milder character, so that the discharges differ less from 
their healthy characters. Under these circumstances, they are 
usually less frequent, not often exceeding six, eight or ten in the 
day, and generally retain their yellow colour or become brownish ; 
they are commonly of a semi-fluid consistence, and may be called 
bilious. When, on the contrary, more frequent, they become fluid, 
abundant, mixed with mucus, and are either of a light yellow or 
brownish, or more rarely of a greenish colour. In some cases 
there are, in addition to the substances mentioned, pus, which indi- 
cates suppuration of the lower portion of the intestine, and frag- 
ments of false membrane. Moreover, it is very common in older 
children to observe traces of blood in the stools, sometimes in con- 
siderable quantities. I may remark that I have several times met 
with stools containing blood in children within the year, but much 
less frequently than after that age. The presence of blood gene- 
rally coincides with small and frequent stools, attended with much 
straining, and often severe pain, and almost always indicates fol- 
licular inflammation and ulceration of the large intestine. 

The serous fluid alluded to sometimes constitutes the whole of 
the discharge, so that the napkins are merely wetted through, with- 
out any or but a very small quantity of solid matter being left 
upon them. This kind of stool is very frequent in the cholera in- 
fantum of this country. The odour of the stools is important. In 
the beginning, while the discharges still retain some of their na- 
tural characters as to colour and consistence, it is often very offen- 
sive, but as the case goes on, and the greenish colour predominates, 



SYMPTOMS. 271 

it is either sour, or becomes very slight. In some violent cases, 
in which the discharge consists of a watery, dark-brown fluid, the 
odour is fetid. 

After diarrhoea, the most important symptoms are those which 
concern the form, size, and tension of the abdomen, and the pre- 
sence or absence of pain or tenderness on pressure. In infants 
the abdomen is more distended than usual ; but, according to Bou- 
chut, the tension depends on the muscular effort made by the child 
to resist the hand of the physician. Fie says that when it is care- 
fully examined, while the attention of the child is attracted in some 
other direction, it is found to be soft and supple, and rarely painful 
to the touch. In older children it is, in many acute cases, but not 
in all, enlarged, sometimes tense and sonorous, and very generally 
painful to the touch. The seat of pain is variable, but generally 
occupies one of the iliac fossse or the umbilicus. It is seldom 
acute, though the child not unfrequently shrinks away and cries 
out, from fear of the examination, as though it were excessive. It 
is easy to distinguish when the pain is real and when apparent, by 
withdrawing the attention of the child, by some device, from the 
examination, in which case it will cease to notice the palpation 
more than is natural under the circumstances ; or by touching 
some other part of the body, when, if the crying and shrinking 
depend on fear or nervous excitation, they will be as violent as 
when the abdomen is touched. Pain to the touch is an important 
symptom, as it is very generally indicative of acute enteritis. 
Gurgling is rare, according to Rilliet and Barthez, in ordinary 
entero-colitis, though very generally present in typhoid fever. 

Vomiting is very common in young infants, and is generally 
repeated several times a day. In severe and rapid cases it is a very 
troublesome and alarming symptom. In older children it is much 
less common, and is never really violent, except in some of the 
most acute cases. In them it is confined to the first {ew days 
of the attack. 

After the diarrhoea is fairly established, young infants arc almost 
always cither very irritable, peevish, and restless, or weak, languid, 
and subdued. Their slumber is short and disturbed, and generally 
they sleep much less in the twenty-four hours than when in health, 



272 ENTERO-COLITIS. 

unless under the influence of anodynes. Older children are gene- 
rally somewhat restless and irritable, but much less so than in- 
fants. There is seldom any disorder of the intelligence, though 
in acute cases there is sometimes slight delirium or headache. 
Fever exists in all acute cases. It is seldom continuous in infants 
except for the first few days, after which it almost always assumes 
the remittent type. It is marked by increased frequency of the 
pulse, which rises to 120 and 140, or in bad cases much higher; 
by heat of skin, often intense during the exacerbations ; by thirst 
and diminished appetite ; and by dryness and heat of the mouth. 
In older children the pulse is not generally so high as in infants, 
and in many of the mild cases the fever is very slight or there is 
none at all. In acute cases, however, it is sometimes continuous 
and marked by rapid pulse and great heat of skin. 

The tongue is generally normal, though sometimes red on the 
edges and tip in acute cases. It is seldom dry, except during the 
fever. Appetite is almost always lost, and thirst generally in- 
creased, though to a less degree than in diseases of the stomach.. 

The countenance presents nothing peculiar except that the fea- 
tures are, according to Rilliet and Barthez, drawn down towards 
the inferior portion of the face. Emaciation always takes place as 
the disease progresses, and in very severe cases, occurs with the 
greatest rapidity, so that in a very few days the child will be re- 
duced from an appearance of vigour and strength, to that of the 
greatest debility. As this occurs the flesh loses its firmness, the 
skin hangs in folds upon the trunk and limbs and is dull and 
dirty in its tint, the eyes become sunken and surrounded with 
bluish circles, and the whole appearance of the child is that of 
misery and exhaustion. 

In infants it is very common to meet with erythema of the but- 
tocks and thighs, produced by the contact of the acrid stools and 
urine with those parts. This symptom is said by Bouchut to exist 
in five-sixths of the cases. I feel quite sure that it does not exist 
in so large a proportion of those which occur in private practice, 
though I have met with it in some instances. When severe it is 
generally accompanied by papules which ulcerate after a time and 
form superficial ulcerations upon the skin. These ulcerations 



SYMPTOMS. 273 

sometimes run together and become of considerable size and depth. 
In the form of the disease met with in the children's hospitals in 
Paris, erythema and ulcerations of the heels and internal malleoli 
are also met with, and constitute a serious complication in the 
case. They are said to depend on want of cleanliness, and the 
rubbing together of the feet of the child, unprotected by covering. 
I have never met with them in private practice. 

The duration of the disease is stated by the French writers to 
be generally about fifteen days, at the end of which time conva- 
lescence is usually established. It may be shorter or longer. Ac- 
cording to my own experience it is entirely uncertain. Most of the 
cases that have come under my notice have been rather shorter. The 
disease subsides gradually. The number of stools diminishes ; 
they become less abundant and more consistent, and return to their 
natural colour and odour ; the pain on pressure, and the enlarge- 
ment and tension of the abdomen disappear ; and as this occurs, 
the fever subsides, the appetite returns, the temper improves, and 
the child enters into full convalescence. 

The chronic form of entero-colitis generally follows the acute, 
though it sometimes presents many of the features peculiar to it 
from the first. It differs from the acute form chiefly in the ab- 
sence or the much slighter degree of fever and other constitutional 
symptoms in the early stage. The diarrhoea is less abundant and 
less frequent. At first the child retains its spirits and many of the 
signs of health. But gradually its strength fails, the temper be- 
comes irritable, the complexion grows dark, sallow, and unhealthy, 
the skin becomes dry and harsh, and in consequence of the emacia- 
tion which takes place progressively with the other symptoms, 
hangs in folds around the shrunken extremities, or is drawn tightly 
over the joints and other osseous protuberances. The tongue is 
generally moist and natural, though in some cases red and dry, 
whilst in others it, together with the lips, partakes of the pallor 
which pervades all parts of the body. The abdomen is usually 
distended and sonorous on percussion, and may be painful or not 
on pressure in different cases, or in the same case at different 
periods of the disease ; its parietes sometimes offer no resistance 
to the touch, so that the intestinal convolutions may be readily felt 



274 ENTERO-COLITIS. 

by the hand, or even between the fingers ; and in some cases I 
have seen them so thin and relaxed, though the abdomen was more 
prominent than natural, that the outlines of the intestines, and even 
the peristaltic movements were visible upon the exterior. The 
appetite generally persists in spite of the gravity of the disease, 
and is sometimes increased. The stools, as has been stated, are 
not so frequent as in the acute form, seldom numbering over six 
or ten in the day and night. They consist of the products of an 
imperfect digestion, not un frequently containing the alimentary 
substances in the state in which they were swallowed, mixed with 
mucus, serum, pus, and sometimes blood. Their consistence 
varies constantly, but they are usually semi-fluid. Their odour is 
seldom natural, but often extremely offensive. 

The course of the disease is very irregular. Even in the worst 
and most prolonged cases intermissions or remissions occur, so 
that the child will often improve greatly for days or weeks, and 
then suddenly relapse into as bad a condition as ever. In favoura- 
ble cases these remissions become more and more frequent, and 
the symptoms gradually improve, until at length the child is re- 
stored to health. In fatal cases death is occasioned by the utter 
deterioration of the general health which finally occurs, and the 
child perishes worn out by long illness, or, as more frequently 
happens, some complication arises which hurries on the fatal event. 
Thrush is a frequent complication of chronic entero-colitis, and 
doubtless often hastens the death by the impediment which it oc- 
casions to the nursing or feeding of the child. Vomiting has 
almost always occurred towards the close of the fatal cases that 
I have seen, especially in those in which extensive thrush was 
present. 

The duration of this form is of course very uncertain. It may 
last for weeks or months. I have known it to last two and three 
months in several cases, and in two others it lasted with occasional 
intermissions, in one a year, and the other eighteen months. 

Diagnosis. — The diagnosis of acute entero-colitis is not dif- 
ficult. There is no disease with which it is likely to be con- 
founded. The characteristic features of the malady are the diar- 
rhosa and other abdominal symptoms, and the absence of signs of 



PROGNOSIS TREATMENT. 275 

other disease. The secondary cases are distinguished by the oc- 
currence of the usual symptoms of entero-colitis during the pro- 
gress of the primary malady. 

The chronic form is not likely to be mistaken for any other dis- 
order, unless it be the diarrhoea which occurs in tubercular disease, 
from which it is to be distinguished by the presence in the latter of 
the signs of tuberculization of other organs. 

Prognosis. — Acute entero-colitis is always a serious disease in 
infants. The prognosis will depend in great measure on the cir- 
cumstances under which the affection has been developed. It is 
much more unfavourable in a child fed on artificial diet, either 
wholly or in part, than in one who is nursed at a fine breast of 
milk. It is more unfavourable also in weak and delicate than in 
robust and vigorous children, and in those of poor people, who 
live in crowded unhealthy portions of cities and towns, whose 
habitations are small, damp, and ill-ventilated, and whose food is 
coarse and insufficient or improper, than in those placed in more 
fortunate and more healthful hygienic conditions. In hospitals for 
children it is a very fatal disorder, owing to the bad hygienic con- 
ditions under which the inmates are placed. In children, who 
have passed through the first dentition, the prognosis is, as a rule, 
favourable. The disease is seldom dangerous when it occurs as a 
primary affection, while as a secondary affection, on the contrary, 
it is much more apt to be serious. 

The unfavourable symptoms are : great frequency of the stools ; 
collapse ; violent vomiting or retching ; and dangerous cerebral 
symptoms, as coma, rigidity of the limbs, paralysis or convulsions. 

Treatment. — The prophylactic treatment of the disease is im- 
portant. It includes attention to diet, dress, exercise, and habita- 
tion. It has already been stated that one of the most frequent 
causes of the malady is the attempt to bring up the child on arti- 
ficial diet, and particularly on one of an improper kind. It is 
clear, therefore, that to avoid the disease, it is necessary that the 
child should, if possible, be nursed. If this cannot be done, the 
diet ought to be wisely selected and regulated in all its details by 
the physician. The one which is most proper is evidently that 
which most resembles the natural aliment of the infant. In my 



276 ENTERO-COLITIS. * 

hands that which has best succeeded is prepared of cow's milk 
mixed with a small quantity of cream, and with water in which 
a certain proportion of gelatine has been dissolved, in the manner 
described at page 193. A regimen consisting of farinaceous sub- 
stances prepared with water alone, or milk and water alone, has 
not answered in my hands nearly so well as that preparation. It 
is particularly important that the food should not be made too 
thick, whatever its ingredients may be. For this reason thick 
gruels of all kinds, cracker food as it is called, bread and milk, or 
thick rice and milk, should be absolutely forbidden to children 
under eight or ten months or a year old. Though I have seen 
some few children thrive upon such diet, the great majority suffer 
from frequent attacks of indigestion and simple diarrhoea, or are 
seized with entero-colitis, and either perish, or make it necessary 
to change the diet. 

The dress ought to be arranged according to the season. Ex- 
ercise in the open air is of the utmost importance, so much so, 
indeed, that every effort should be made to insure a certain 
amount of it every day. This is, after diet, the most important 
point in the prophylactic treatment. 

Diet in the attack. — After the disease has made its appearance, 
the diet should be very carefully regulated. This constitutes, in 
truth, the most important point in the treatment. If the child is 
nursing, it ought to be confined entirely to the breast, and should 
the nurse have a large quantity of milk, must not be allowed to 
nurse very often, nor very long at a time. If there be the least 
suspicion that the milk of the nurse is unhealthy, it should be ex- 
amined with the microscope, and if found to contain colostrum 
granules, a new nurse must be provided. If the disease comes on 
shortly after weaning, and persists for several days in spite of care- 
ful diet and treatment, it is safest to restore the child to the breast. 
When this cannot be done, we must select that form of artificial 
diet which seems most suitable. The best is, in my opinion, the 
cow's milk prepared with the solution of gelatine in the manner 
already recommended, but made very weak for a few days. I have 
often found it necessary, under these circumstances, to add four and 



TREATMENT. 277 

even more parts of water to the milk, instead of two or equal 
parts, as is the usual custom. 

In older children the diet, for a few days, ought to consist of 
nothing but barley or arrow-root water ; after which thin prepara- 
tions of arrow-root, rice-flour, sago, tapioca, or wheat-flour, made 
with milk, or milk and water, with small quantities of bread, or, if 
the child refuse such articles, panada, or very thin chicken or mutton 
water may be allowed. The quantity of food, whatever it be, 
ought to be much less than usual, and in very severe attacks must 
be just enough to sustain the strength of the child, and no more. 
This system of diet is to be persevered in until the disease is re- 
moved, unless the child refuses it absolutely, in which case, we 
may allow pure milk, small quantities of ice cream, a little bread 
and butter, and small portions of chicken or mutton, well cooked, 
and cut up very fine. The return to old habits as the child re- 
covers, or after full convalescence is established, ought to be made 
carefully and gradually, as there is no disease in which relapses 
are so apt to occur from neglect of this precaution. 

IVierapeutical Treatment. — I have found a large number of the 
mild cases that have come under my notice, all of which occurred 
in private practice, to recover under very simple treatment. When 
the patient is an infant at the breast, before the period of dentition, 
the simple direction not to allow it to nurse as much as usual, the 
use of a warm bath morning and evening if the skin be heated 
and the child restless and fretful, the administration of a small 
dose of castor oil, (half a teaspoonful to a teaspoonful,) or of spiced 
syrup of rhubarb in the same quantity, with half a drop to a drop 
of laudanum, followed in one or two days, if the disorder continues, 
by some simple astringent remedy, generally suffices to effect a 
cure. When, on the contrary, the case depends on an unhealthy 
or insufficient milk, when the child subsists entirely on artificial 
food, and when the disease coincides with the process of denti- 
tion, the attack is kept up and aggravated by these causes, and 
it is more difficult to obtain a cure. In the former case the diet 
is, of course, of all importance. In the latter, the gums must be 
carefully examined, and if found to be swelled and inflamed, and 
the teeth near the surface, should be freely incised. After these 

24 



278 ENTER0-C0LITIS. 

matters have been attended to, the kind of treatment will depend 
on the character of the general symptoms and the violence of the 
enteritic disorder. When the fever is violent, the discharges fre- 
quent, painful, and mixed with mucus or blood, and the abdomen 
tumid, tense, and painful to the touch, it is proper to make use of 
depletion in strong and hearty children. When, on the contrary, the 
child is pale and delicate, it is better, it seems to me, to dispense 
with bloodletting in any form. In young infants only leeches need, 
as a general rule, be used. They should be applied over the seat 
of tenderness, generally one of the iliac fossse, in such number as 
to take about an ounce of blood, or in very hearty, sanguine 
children, two ounces. Dr. Stokes (Loc. cit.) is of opinion that it 
is sometimes necessary to bleed, even in infants, as he has seen 
the disease resist detractions of blood by leeching, and yield im- 
mediately to venesection. When it is impossible to bleed from the 
arm, he proposes the application of a leech or two to the back of the 
hand or foot, and then immersing the part in warm water, by 
which method he states that a considerable quantity of blood may be 
obtained. In such instances I have always been able to bleed the 
child from the saphena vein as it runs over the inner malleolus, 
and would much prefer this plan, because we can readily observe 
the amount of blood that flows, which cannot be done when the 
blood is allowed to flow into water. Dr. Stokes recommends a 
second application of leeches should the first fail to relieve the 
symptoms. In older children we may substitute venesection for 
leeching if we deem it better, taking from two to six ounces of 
blood according to the age and strength of the patient. During 
the fever the use of ivarm baths at about 96° or 97° will be found 
of very great service. They should be employed once or twice, or 
even three times a day, if the heat of skin, frequency of the circula- 
tion, and restlessness, continue. It will often be found very bene- 
ficial to envelope the child in a warm blanket for half an hour 
after the bath, as this will sometimes produce fine perspiration. 

The internal remedies during the early stage should consist of one 
or two laxative doses, guarded by small quantities of an opiate ; or we 
may administer what is regarded with great favour by most physi- 
cians in this country, calomel. When the febrile symptoms are 



TREATMENT. 279 

strongly marked, I believe that this is a very useful remedy in many 
instances. It is given differently by different practitioners. Some 
prefer one or two large doses, while others use it in minute quan- 
tities, and repeat it more frequently. It seems to me that this 
ought to depend on the nature of the attack, and the age and 
constitution of the child. In delicate subjects, and those within the 
year, I would always prefer to employ small doses, about a quarter 
or sixth of a grain, to be repeated every two hours until a grain 
has been taken, after which I would administer a small quantity 
of castor oil or syrup of rhubarb. In stronger and older children, 
on the contrary, in whom the attack is violent, it is often more 
useful to give from one to four grains in a single dose, and follow 
it by the laxative in a few hours. 

Dr. J. Cheyne (ioc. cit.) recommends calomel very strongly in 
the treatment of the disease, which, as has been stated, he calls 
atrophia ablactatorum. He gave it in doses of half a grain morn- 
ing and evening, continued for a week or ten days, or until the 
discharges assumed a more natural appearance. Dr. Stokes (Lgc. 
cit.) states that the internal remedies from which he has obtained 
the most advantage, are a combination of a mild mercurial with 
Dover's powder, and gummy solutions. The mercurial which he 
employs is the hydrargyrum cum creta. 

I am very much in the habit, in all cases of entero-colitis, of 
administering opiates in some form. Some writers object to their 
employment in the early stage as injurious. I have never been 
deterred from using them, however, except in cases presenting 
manifest signs of cerebral irritation in connexion with the febrile 
symptoms. When there has been nothing more than irritability, 
restlessness, and insomnia, when there is evident pain during the 
discharges, and when the latter have been very frequent, I have 
always made use of such remedies without hesitation, and I 
believe without injury, but on the contrary, with very great be- 
nefit. I am very glad to find that Dr. Stokes also employs opium 
without hesitation. He says " it is a remedy that requires caution 
in its exhibition, but one of great utility." It generally lessens 
the number of discharges, and very often it seems to me, dimi- 
nishes the heat of skin and frequency of the circulation, by allay- 



280 ENTERO-COLITIS. 

ing irritability of the nervous system, and at the same time greatly 
promotes the comfort of the child. I have used it in the form of 
laudanum or paregoric, given in combination with a laxative early 
in the case, or by enema, and afterwards in that of the Dover's 
powder or powdered opium, mixed' with calomel. For a child 
under six months old half a drop of laudanum is enough to give per 
orem. Of the Dover's powder, about a sixth or eighth of a grain 
may be administered mixed with the same quantity of calomel, to 
be repeated every two or three hours until three or four doses have 
been taken, or until the child shows some degree of drowsiness 
from the action of the opium, after which it ought to be suspended 
for six or eight hours, and then resumed. If it is desirable to give 
the opiate by enema, about one or two drops may be administered 
in a tablespoonful of thin starch. In cases of older children, the 
doses must of course be larger. For those more than a year old, 
about two drops of laudanum may be given with castor oil or rhu- 
barb ; or a quarter of a grain of Dover's powder with the same 
quantity of calomel, or finally, from two to four drops of laudanum 
by enema. During the acute period of the disease, and particu- 
larly when the abdomen is distended and painful, warm mush 
poultices, made light and thin, placed between pieces of flannel, and 
applied over that region, will be found very useful and soothing 
remedies ; they should be renewed every few hours. 

Generally speaking the acute constitutional symptoms either 
subside or disappear under the above treatment, and very often the 
diarrhoea also ceases and the child recovers. When, however, the 
diarrhoea persists, it is necessary to resort to two other classes of 
remedies, upon which great reliance is placed in the treatment of 
the affection. These are astringents and absorbents, of which the 
most important are prepared chalk, powdered crab's eyes, acetate 
of lead, rhatany, kino, and catechu. The chalk may be used in 
the form of the officinal Mistura cretse, a teaspoonful of which is 
given after each loose evacuation, or several times a day ; when 
the case is severe, its efficacy is much increased by the addition of 
tincture of krameria, in the proportion of a drachm to two or three 
ounces of the mixture, of some opiate preparation, or of ten or 
fifteen drops of the aromatic syrup of galls (to be described pre- 



j 



TREATMENT. 281 

sently), to each teaspoonful ; chalk may be used also with great 
advantage in powder, combined with Dover's powder, and some- 
times with calomel, or in the form of the Hydrargyrum cum creta, 
which is a favourite prescription of many physicians, in the dose 
of from a quarter of a grain to a grain three or four times a day. 

The powdered crab's eyes will sometimes arrest cases in which 
prepared chalk fails to produce any effect. It is generally em- 
ployed in mixture. The formula which I employ is the follow- 
ing: R. — Ocul. cancror. pulv. 3i ; Acacias pulv. 3ii; Sacch. alb. 
9i ; Aquas fontis, Aquas cinnamom. aa 3iss. Misce. A teaspoonful 
to be given four, five, or six times a day. M. Bouchut recom- 
mends the following prescription of Hufeland's : R. — Ocul. can- 
cror. pulv. gr. x ; Aquas foeniculi, Syrup. Rhei, aa 3ss. Misce. 
Give a teaspoonful every hour. 

Acetate of lead has been highly extolled by many writers in the 
treatment of the diarrhoeas of children. I have had but little ex- 
perience in its use, and am therefore unable to offer an opinion in 
regard to the influence which it may exert. It may be given in 
doses of from a sixth to an eighth of a grain, alone, or combined 
with chalk or Dover's powder, every two hours. Krameria, kino, 
and catechu may be exhibited alone, in the form of infusion or 
solution, or they may be given in conjunction with the chalk mix- 
ture. I have frequently employed the tincture of krameria in the 
latter way, and believe it adds very much to the efficacy of the 
remedy. About one or two drachms may be added to two ounces 
of the mixture, and the usual dose given. I have used, with much 
advantage, either alone or with chalk or crab's eyes mixture, 
an aromatic syrup of galls, in the dose of from fifteen to forty 
drops three or four times a day, or, when the discharges are very 
frequent, every two or three hours. It is prepared according to 
the following formula : R. — Gallae opt. pulv. 3ss ; Cinnamom. 
pulv. 3ij ; Zingib. pulv. 3ss ; Spts. Vini Gall. opt. Oss. Misce. 
Let the ingredients stand in a warm place for two hours, and then 
burn off the brandy, holding some lumps of sugar in the flames. 
Strain through blotting paper. Dr. Eberle (Loc. cit. p. 221) 
highly recommends the root of the geranium maculatum. He 
says it makes an " agreeable and efficient astringent," and is less 

24* 



282 ENTERO-COLITIS. 

apt to derange the digestive organs, and occasion irritation of the 
mucous membrane of the bowels, than kino. He uses it in the 
form of a decoction made with milk, by boiling an ounce of the 
fresh root in a pint of milk, until half is evaporated. The dose 
is from a teaspoon ful to a tablespoonful four or five times a day, 
according to the age of the patient. 

The nitrate of silver is highly recommended as a remedy of late 
years by several writers. It is given both internally and by 
enema. The modes of administration will be described in the 
remarks on the treatment of the chronic form of the disease. 

Revulsives are often of much service in treatment of this, as of 
almost all the diseases of childhood. When there is much restless- 
ness and irritability, with heat of the head and trunk, and coolness 
of the extremities, it will be found that mustard pediluvia, or sina- 
' pisms to the extremities, often allay these symptoms and greatly 
comfort the little patient. When the abdomen is tense and painful 
and the discharges preceded or accompanied by movements or 
crying indicative of pain, the application of a poultice of mush and 
mustard from time to time, to be followed by a simple mush poul- 
tice, sometimes acts very usefully. 

Tonics and stimulants are often necessary in weak and delicate 
children from an early period in the attack, and in those who are 
stronger, after the disease has lasted for some time, and the acute 
symptoms have ceased, and been followed by weakness and ex- 
haustion. The best tonic is, probably, sulphate of quinine in 
doses of from a quarter of a grain to a grain three times a day, 
continued for one, two, or three weeks, if necessary. Old brandy 
has answered better in my hands, as a stimulant, than wine, wine- 
whey, or any of the tinctures. It may be given to the youngest 
children in doses of five or six drops every two hours, or a 
teaspoonful may be added to a wineglassful of sweetened water, 
and a teaspoonful given whenever the child will take it. I 
have been obliged, in several cases, to continue the use of the 
brandy for three, four, and five weeks. At the time when we are 
obliged to resort to this class of remedies, it is almost always 
necessary also to pay attention to the improvement of the diet. 



TREATMENT. 283 

The proportion of milk to water ought to be increased, if it has 
been small heretofore ; and we should employ every means to 
induce the child to take a sufficient quantity without overloading 
the stomach. At this stage small quantities of animal broths are 
proper, or the child may be allowed to suck pieces of juicy meat, 
or to eat very finely minced meat of chicken or mutton. The 
diet is in fact a most important part of the treatment at this 
period. Dr. Stokes says of it that " many children are lost by 
the practitioner neglecting this point." 

Treatment of chronic enter o-colitis. — The management of the 
hygiene of the patient is more important than any other part of the 
treatment, in this, as in nearly all the diseases of the digestive 
organs in children ; for cases will often recover when the diet, 
drinks, and exercise are properly regulated, without the use of any 
drugs whatever, whereas, most assuredly, none or but a very small 
proportion of them would terminate favourably under the best and 
wisest therapeutical medication, were the hygiene of the child 
entirely neglected. The remarks that have been made as to the 
diet most proper in the acute form will apply here. If the child has 
been weaned only a ^ew weeks before the time at which we are con- 
sulted, and the case is at all serious, it is better to advise the procuring 
of a wet-nurse. I have several times known cases of the disease which 
had resisted the most carefully managed artificial diet and thera- 
peutical treatment, recover in a few days after the child had been 
restored to the breast. It is often, however, impossible to follow 
this course, from the refusal of the parents to obtain a nurse, or of 
the child to take the breast of a stranger, and we are obliged to 
rest content with artificial food. I believe that the kind of diet 
which suits the largest number of children is one of milk. Within 
upwards of a year I have found the gelatine food already described, 
to answer better than any that I have ever essayed. It ought to be 
made very light and thin. About a scruple of gelatine should be 
dissolved by boiling in half a pint of water. Towards the end of 
the boiling, a gill of cow's milk and a teaspoonful of arrow-root 
made into a paste with cold water, are to be stirred into the solu- 
tion, and from one to two tablespoonfuls of cream added just at the 
termination of the cooking. It is then to be sweetened moderately 



284 ENTERO-COLITIS. 

with white sugar, when it is ready for use. The whole prepara- 
tion should occupy about fifteen minutes. 

When cow's milk, mixed with water alone, or prepared in the 
manner just recommended, evidently disagrees, I have sometimes 
found cream with water alone, or better still, with the solution of 
gelatine in water, in the proportion of one part of cream to five or 
six of the latter, to suit very well. In other cases, very carefully 
prepared chicken or mutton water, given several times a day, or 
but once, according to the taste and fancy of the child, will answer 
better. It sometimes happens that the child will refuse everything 
that has been mentioned, and yet the prostration and emaciation 
are such as to make it essential to procure some aliment that it 
will consent to take. I have, under such circumstances, given 
small portions of bread and butter, or stale sponge cake, with weak 
brandy and water, if the child is old enough to swallow solid food. 
Sometimes it will eat small quantities of meat, and when this has 
been the case, I have not hesitated to allow a chicken bone, with 
a little meat attached to it, or a piece of ham, or better still, a por- 
tion of roast beef, or of the tender loin of beef-steak, to be held in the 
hand and sucked ; or we may give the white meat of chicken cut 
up very fine, or torn into the finest shreds. Of the latter about a 
teaspoonful is sufficient for the first day, given with a little brandy 
and water. The quantity can be gradually increased afterwards. 
There is another article which I have sometimes given when 
children have been exhausted for want of food, and when they re- 
quire constant change in order to be tempted to take it. This is 
the yelk of a hard-boiled egg, which has the great advantage of 
being very nutritious if digested, and of not being injurious, should 
it happen to pass into the bowel in the crude state, as it falls into a 
state of fine powder, which is not irritating to the mucous coat. 

The quantity as well as quality of the food is of the utmost 
importance, and should be strictly regulated by the physician, and 
attended to by the mother or nurse. As a general rule the child 
may be allowed as much as it wants of proper food, since the 
appetite is almost always greatly diminished, and it is not likely 
therefore, that too much will be taken. If, however, there is 
disposition to nausea or vomiting, or, if the appetite remains as 



TREATMENT. 285 

good as usual, the quantity must be restricted. The difficulty in 
most cases is to get the patient to take enough, and not to prevent 
it from taking too much, for I have very often ascertained upon 
careful inquiry, that the quantity was entirely too small to support 
the strength of the constitution. A hearty child, six months old, 
fed solely on artificial food, will generally take between a pint 
and a quart of fluid in the twenty-four hours, while at a year old, 
it will take usually fully a quart or more of fluid nourishment, 
besides eating small quantities of solid food. Now, T have fre- 
quently known children labouring under chronic entero-colitis, not 
to take more than one or two gills of food in the day, which is 
manifestly much too little.*^ When this is the case, therefore, we 
should always endeavour to stimulate the appetite and digestion by 
means of tonics and stimulants, and by causing to be presented to 
the child such a variety of food as may entice it to take a larger 
quantity than before. 

The therapeutical treatment of the chronic form consists prin- 
cipally in the administration of tonics, astringents, and absorbents. 
Of these the most important are the powdered chalk and crabs'- 
eyes, and the different vegetable astringents, which have already 
been noticed in the remarks on the acute form. These are to be 
given in the manner there recommended, and it is therefore unne- 
cessary to repeat what has already been said. In addition to these 
there are some remedies which are particularly adapted to the 
chronic form of the disease. Amongst them are nitrate of silver. 
Dr. Eberle (Loc. cit. p. 251) says he has found its internal ad- 
ministration to produce the happiest effect in a few instances. His 
prescription was a grain of the nitrate dissolved in an ounce and 
a half of gum arabic water, with the addition of twenty drops of 
laudanum. The dose was a teaspoonful three times a day. He 
adds that he has never " known the slightest inconvenience to re- 
sult from the use of this article in chronic mucous inflammation of 
the bowels, when administered in a mucilaginous solution and in 
very small doses." It has been much used of late years in France. 
MM. Trousseau and Pidoux recommend its internal use in the 
chronic diarrhoeas of children occurring during dentition, after 
bismuth, powdered crabs'-eyes, and diet have failed to effect a 



286 ENTERO-COLITIS. 

cure. Their formula is as follows : R. — Argent, nitrat. gr. ^ ; 
Aquae destillat. 3vi ; Syrup, sarsp. 3iiss. — Misce. To be given 
in eight or ten doses. At the same time they employ an enema 
composed of a grain of the nitrate in three ounces of distilled water. 
It is highly recommended also in these cases by Hirsch of Ko- 
nisberg. His formula is as follows : R. — Argent, nitrat. crys- 
tall. gr. I ; Aquse destillat. 3ii ; Acaciae pulv. Bii ; Sacch. alb. 
3ii. — Misce. A teaspoonful of this mixture to be given every two 
hours, and an enema, consisting of a quarter of a grain of the 
salt, with mucilage and a little opium, to be administered. (Rank- 
ing' s Abst. No. vi, p. 61.) I have employed this remedy in the 
proportion of from half a grain to a grain in a gill of water, by 
injection, morning and evening for several days, with very decided 
benefit, in three cases of diarrhoea following summer-complaint, 
in which the stools were frequent, mucous, sometimes streaked 
with blood, and accompanied by tenesmus. Trousseau and Pidoux 
also recommend in this class of cases the sub-nitrate of bismuth 
in the dose of from two to nine grains in the twenty-four hours. 
It may be given in powder, or suspended in syrup or milk. Bou- 
chut recommends injections of from ten to twelve grains of extract 
of rhatany, or six to ten of tannin in about five or seven ounces of 
some vehicle. 

Drs. J. Cheyne, Eberle, Dewees, and Condie, all recommend 
calomel in the treatment of the chronic disease. I am of opinion 
that it is often useful when given in very minute doses (i to T V of a 
grain), in combination with Dover's powder, three or four times a 
day, for three or four days, after which I would rather depend on 
astringents combined with opiates, and upon the use of injections 
of nitrate of silver. I have in several cases derived considerable 
benefit from the use of Hope's camphor mixture given in the 
dose of from five to fifteen drops three or four times a day in 
water. 

It should never be forgotten in the treatment of chronic diar- 
rhoea in children, that the most important point of all is the regu- 
lation of the diet and other hygienic conditions. I am fully con- 
vinced that I have seen several children saved from death by 
attention to these points, and by the persevering and careful em- 



TREATMENT. 287 

ployment of tonics and stimulants. It often happens, after the dis- 
ease has lasted for some weeks or months, that the function of the 
stomach is almost wholly lost. The child either refuses food or 
takes so little that the quantity is evidently insufficient to carry on 
the vital processes, or the greater part of what it takes is rejected by 
vomiting, or lastly, much of it passes off through the bowels, and 
appears in the stools in an undigested state, forming what is called 
lientery. If this condition of things is allowed to continue the 
emaciation and exhaustion make rapid progress, and the case must 
soon terminate fatally. Under these circumstances all the inge- 
nuity and skill of the physician are required to find means to re- 
store vigour to the digestive function, and to recall the appetite of 
the patient. If the stomach is frequently sick it is best to abandon 
all remedies but those which are stimulating and strengthening, 
and especially to forbid all such as are in the smallest degree 
nauseous. I would indeed depend entirely on the use of repeated 
doses of the oldest and most delicate brandy that could be found, of 
which from one to two teaspoonfuls may be put into a wineglassful 
of cold water, and the whole given b}^ teaspoonfuls in the twenty- 
four hours. At the same time, the food ought to be chosen with 
the greatest care, endeavouring always to please the fancy of the 
child as much as possible, and it should be given in very small 
quantities often repeated. While this is being done, an occasional 
dose of anodyne, just enough to tranquillize without stupifying, 
may be given. If the rectum will retain it, it is better to give 
it by enema. In some cases I have found the aromatic syrup 
of galls given with brandy, to be taken by the child without any 
difficulty or disgust. 

Exercise and exposure to the air are all-important. In some 
very severe and tedious cases, change of residence or travelling 
has been known to effect a cure after all remedies and other means 
had failed. In one case, in this city, which had lasted with but 
short intervals for two years, I obtained a perfect cure by per- 
suading the parents to send the child into an elevated part of the 
country in the month of May, where it was kept until July, after 
which it was removed to the seaside until the end of August. 
Nothing was done in the mean time except to regulate the diet 



288 CHOLERA INFANTUM. 

most carefully, and to keep the child the greater part of the day 
in the open air. 



ARTICLE III. 

CHOLERA INFANTUM. 

Definition; synoiiymes ; frequency. — Cholera infantum can 
be defined only by an enumeration of its characteristic features. 
These are its occurrence in very young children, and in the sum- 
mer months ; the evidences in the early stage of violent irritation 
and hypersecretion of the gastro-intestinal mucous surface, and at 
a later period of inflammation, ulceration, softening and thickening 
of the same surface, particularly of the ileum and large intestine ; 
its chief symptoms are vomiting and purging ; fever, generally of 
a remittent type, varying often with collapse ; rapid emaciation ; 
and towards the close, violent cerebral symptoms. 

The common name of the disease is summer complaint. Though 
rare in Europe, in comparison with its frequency in this country, 
it is nevertheles described with sufficient accuracy to point out a 
clear identity of the two, by Billard, under the title of follicular 
enteritis ; by Barrier, under that of apyretic and febrile follicular 
diacrisis, the latter term being taken from Gendrin ; and by Cop- 
land under that of choleric fever of infants. 

It is of all the diseases which prevail amongst children in this 
country, one of the most frequent and important. It appears from 
Dr. Emerson's tables (Am. Journ. Med. Sciences, vol. i, 1827), 
that from 1807 to 1827, a period of twenty years, there were 
3576 deaths from cholera under five years of age. This is the 
largest number of deaths, from any one disease, given in the table. 
The next largest item of mortality is under the head of convulsions, 
of which it appears that 3192 died in the same period of life. 
From Dr. Condie's table (Dis. of Children, note, p. 89), it appears 
that during the ten years preceding 1845, there were 2583 deaths 
from cholera infantum, all of which occurred under five years of 
age. During the same period of years there were 2712 deaths 
from convulsions in children under five years of age, and 1452 



causes. 289 

from pneumonia. Cholera infantum, therefore, causes about as 
many deaths as convulsions during the first five years of life, 
and considerably more than pneumonia. Again, if we com- 
pare the respective mortality from the three diseases named, 
which appear by the above tables to be the most destructive during 
the period of childhood, or under fifteen years of age, we find the 
proportion not much altered ; for, while there were 2583 deaths 
from cholera infantum, there were 2824 from convulsions, and 
1592 from pneumonia. 

Causes. — The most influential predisposing causes are the heats 
of summer, the impure air and want of ventilation of cities, denti- 
tion, improper diet, early age, and hereditary influence. 

Heat. — That the heats of summer, constitute a powerful predis- 
posing cause to the disease is proved by the evidence of almost all 
writers, and by the fact that the disease occurs in its most charac- 
teristic and peculiar form only during the warmest months of the 
year. Dr. Lindsly {Am. Journ. Med. Set. vol. xxiv, 1839) gives 
a table showing the deaths from the disease in Washington city, 
in the five months of June, July, August, September, and October, 
of 1837 and 1838, from which it appears, that in the former year 
there were 4 deaths in June; 10 in July; 14 in August ; 3 in 
September ; and 2 in October : in the latter year there were 2 
deaths in June; 15 in July; 22 in August; 14 in September; 
and 2 in October. I regret that the deaths per month from the dis- 
ease are not given in the tables of Dr. Emerson, or in those of Dr. 
Condie. It is universally agreed, however, that the disease is 
most frequent and fatal in the months of July and August, that it 
is much less so in June and September, and that in May and Oc- 
tober it is seldom met with. That it is not the heat of the season 
alone, however, is proved by the fact that the disease is less fre- 
quent and fatal in some of the southern cities of our continent than 
in New York and Philadelphia. It is proved also by the following 
table, the materials of which I obtained from the paper of Dr. 
Emerson (Loc. cit.) 

25 



290 



CHOLERA INFANTUM. 





Mean temperature of the 


Total deaths from cholera 


Year. 


three summer months for 
each year. 


in each year. 


1815 


76° F. 


92 


1819 


" 


246 


1818 


74° 


196 


1811 


" 


224 


1817 


u 


130 


1813 


72° 


173 


1812 


70° 


154 


1814 


'« 


125 


1816 


u 


87 



The table is imperfect, because I have been obliged to take the 
whole number of deaths from cholera at all ages for each year, and 
compare them with the mean temperature of the three summer 
months of the same years. It is not, however, so imperfect as this 
would at first view make it appear, since the vast majority of the 
returns under the head of cholera in the table of Dr. Emerson, are 
in fact cases of cholera infantum. This is shown by the fact that 
of 3812 deaths from cholera in the twenty years from 1807 to 
1827, (including the nine years in the above table,) only 236 were 
of persons over five years of age, and of course all the rest (3576) 
were of children, and therefore, cases of cholera infantum. 

The table shows that the number of deaths is not in proportion 
to the mean heat of the season, since in 1815, when the tempera- 
ture averaged 76°, there were only 92 deaths, being only five 
more than in 1816, when the mean heat was but 70°. 

It would seem that in order for heat to produce the disease to a 
great extent, it must be combined with the close, impure air of 
cities. The disease prevails most in the low, thickly inhabited, 
dirty, and badly ventilated streets and lanes of cities, in which the 
atmosphere is loaded with exhalations and effluvia ; while in the 
country, at the distance of but a few miles from q. city in which it 
prevails extensively, it is comparatively very rare, except in chil- 
dren removed from the city. 

Dentiti<m. — I believe this to be a most powerful predisposing 
cause of the disease, and yet it would seem to be less influential 
than age, for the tables of Drs. Emerson and Condie show that the 
disease is about twice as fatal in the first year as in the second, 



CAUSES. 291 

though the process of dentition is certainly more active and con- 
tinuous in the second than in the first year. I have rarely ob- 
served the disease before the beginning of the process of dentition, 
and it is certainly very rare after its completion. 

Age, as has just been stated, exerts a strong influence in the pro- 
duction of the disease. In the tables of Dr. Emerson, the cases of 
cholera infantum and cholera morbus, are included under the one 
head of cholera, but as all cases of the disease under five years of 
age are called cholera infantum, the want of the distinction does 
not make the statements less useful to us. From them it appears 
that there were 2122 deaths in the first year, 1186 in the second, 
and only 268 between the second and fifth. Between five and 
ten years, only 52 cases are noted, and these would of course be 
entitled cholera morbus. Dr. Condie reports 1706 deaths in the 
first year, 752 in the second, 125 between two and five years, and 
nine after that age. 

Sex. — There are no means of ascertaining the exact proportion 
in which the disease occurs in the opposite sexes. Of 24 cases, 
however, of which I have kept a record, 14 occurred in males, and 
10 in females. 

Constitution. — The disease is most apt to occur in feeble, deli- 
cate children, and in those of nervous, irritable temperament. 

Diet. — There can be no doubt that the deprivation of the breast, 
and the use of artificial diet often predisposes to the disease. In- 
deed, weaning in the summer, and the resort to artificial food, is 
often an exciting cause, the disease making its appearance not un- 
frequently very soon after the change has been made. M. Bar- 
rier states that the use of feculent substances, often ill cooked or 
sweetened with too much sugar, as diet, is one of the most frequent 
causes of the follicular diacrises of young children. This agrees 
exactly with the opinion of M. Valleix as to the most evident cause 
of the enteritis and thrush, so fatal amongst the children of the 
Foundling's Hospital at Paris. He states it to be improper ali- 
mentation, and particularly one consisting of feculent materials. 
He adds that he has never known a child nourished exclusively at 
the breast during the early months to have the disease. [Guide 
du Med. Prat. t. iv, p. 60.) The use of too indiscriminate a diet 



292 CHOLERA INFANTUM. 

during the second year is another frequent cause of the disease. 
I have several times known it to follow the giving a child the 
smallest quantity of fruit. For a more detailed account of the 
influence of diet in the production of diseases of the intestines in 
children, the reader is referred to the article on entero-colitis. 

Hereditary predisposition. — My own observation leads me to 
believe that the disease is apt to occur in certain families. It would 
seem probable that this peculiarity, if it exists, must depend on the 
fact that the constitutions of some families are particularly disposed 
to disorders of the digestive apparatus. I am acquainted with one 
family in this city, in which eight out of ten children, suffered 
more or less from the disease. Again, of these children, four have 
grown up, married, and have children. Two of these families 
have each lost a child from the disease ; in a third, the two chil- 
dren of the family have been exceedingly ill with it ; while in 
the fourth, some of the children have been sick, though not to the 
same degree. Again, I have attended this summer (1847), two 
children in a family, one not quite two years, and the other 
three months and a half old, who have both been very sick with 
the disease. The elder child was ill the summer before in the 
same way. The mother of these children was herself very ill 
with the disease on several occasions during her infancy, as was 
also her brother. 

Anatomical lesions ; nature of the disease. — The best accounts 
of the anatomical lesions observed after cholera infantum will be 
found in Stokes and Bell's Practice (2d edit. vol. i, p. 474-483) ; 
in Dr. William E. Horner's paper ( Am. Journ. Med. Sciences, 
Feb. 1829) ; and particularly in Dr. E. HallowelPs article on En- 
demic Gastro-follicular Enteritis, in the same journal for July, 
1847. 

The nature of the lesions depends on the severity of the case, 
and the stage at which the fatal event took place. When death 
occurs early, the only lesions found are unusual development of 
the mucous follicles or glandular apparatus of the stomach and 
bowels, implicating chiefly the isolated glands, and in a smaller 
number of cases the agminated glands or plaques of Peyer. In 
severer cases, and those which have lasted longer, the lesions ob- 
served are more important, and consist in inflammation and soften- 



ANATOMICAL LESIONS. 293 

ing of the mucous membrane, and ulceration of the follicles, some- 
times to a great extent. 

Having already described with considerable minuteness, in the 
article on entero-colitis, the morbid alterations of the follicular 
apparatus of the gastro-intestinal canal, I shall not repeat the de- 
scription in the present place, but merely allude to the alterations 
by name, referring the reader for a more particular account to the 
former place. The description of the lesions of cholera infantum 
which follows, is derived from the analysis of seventeen autopsies 
of the disease, three of which were made by Professor Horner of 
this city, and fourteen by Dr. Hallowell, {loc. cit.) 

Stomach. — The mucous membrane presented traces of inflam- 
mation, in the form of arborizations or injection in 6 cases, while 
in 10 the colour was noted as pale or natural. Softening to a 
greater or less extent was noted in 1 cases ; in 4 the consistence 
was natural ; in 3 it is not mentioned. The condition of the 
mucous crypts is given in 6 : in one not apparent ; in one scarcely 
visible ; in one slightly developed ; in 2 distinct, but not much de- 
veloped ; in one largely developed. 

Small intestine. — Traces of inflammation of the mucous mem- 
brane were noted in 7 cases, confined generally either to the duo- 
denum or ileum, and affecting onty a small extent of the bowel ; in 9 
the membrane was noted as pale ; and in one its appearance is not 
mentioned. Softening existed in 5 cases, slight in all ; in 7 the 
consistence was natural, while in the remainder tne consistence is 
not mentioned. The isolated crypts are noted as numerous and 
distinct in 2 cases, as slightly developed in 9, as distinct in the 
ileum, and not in other parts in 2, and in the duodenum in one ; in 
3 their condition is not mentioned ; in 2 only they were slightly 
ulcerated. The agminated glands are stated to have been natural 
in G ; they were more developed than usual, and generally red- 
dened, in 6 ; in 5 their condition is not given; they were not 
ulcerated in any of the cases. 

Large intestine. — The condition of the mucous membrane as 
to inflammation is not mentioned in 2 cases ; in 9 it is stated to 
have been more or less inflamed throughout ; in 2 the inflamma- 
tion was confined to the rectum or the lower part of the colon ; in 

25* 



294 CHOLERA INFANTUM. 

4 the inflammation was slight, and in 2 of these existed only 
around the follicles. The consistence of the membrane is not 
mentioned in 6 ; it was found more or less softened in 9, thickened 
in one, and normal in one. The muciparous crypts are stated to 
have been developed, without any reference to the presence or 
absence of ulcerations in 3 cases ; to have been developed with 
a few ulcerations in 3 ; much developed with many ulcera- 
tions in 7 ; and finally to have been developed and not ulcerated 
in 4. The character of the ulcerations is not mentioned in all the 
cases. In some it extended to the sub-mucous tissue, and in a 
few to the muscular. The ulcerations of the crypts are generally 
most marked in the rectum. 

The stomach often contains a good deal of mucus adhering to 
the lining membrane; the small intestines contain orange-coloured 
mucus ; while the large bowel generally contained mucus ad- 
hering to the inner coat, and a good deal of thin faecal matter of 
a grayish colour. 

Dr. Hallowell {hoc. cit. p. 49) states that in patients who died 
during the second stage, that is, before the appearance of dan- 
gerous cerebral symptoms, the lungs presented nothing remarkable 
beyond a slight engorgement posteriorly, except in three cases in 
which the children had had measles or hooping-cough, and one in 
which pleurisy had followed exposure to the night air. " The 
peritoneum presented its usual healthy colour in all the cases ob- 
served ; the liver was greatly enlarged in but a single instance, 
contrary to the statements of most authors, who affirm this to be 
uniformly the case ; the gall bladder was more or less distended 
with dark-coloured bile, staining the finger a deep yellow ; the 
mesenteric glands were not enlarged ; the spleen and kidneys pre- 
sented nothing remarkable." In regard to the brain he states that 
in most of the cases the veins of the pia mater were more or less 
distended, and the membrane injected also, but that the injection 
was generally confined to the larger ramifications ; the substance of 
the brain presented injection of the central portion in one, and of the 
central and cortical portions both in another ; there was softening 
in four cases, and little or no effusion in the ventricles. In patients 
dying in the third stage, with stupor, convulsive movements, 
rigidity or paralysis, there were found, in addition to the morbid 



i 



NATURE. 295 

appearances already described, disorganization of the structure of 
the brain from softening of its tissue. The softening, sometimes 
general, was more frequently confined either to the cortical sub- 
stance, or to the central portions of the brain and cerebellum. The 
softening may be such that the brain will readily give way on 
slight pressure, or its substance may be so diffluent as to resemble 
cream. The substance of the brain commonly presents numerous 
red spots from effusion of blood ; the pia mater is more or less in- 
jected and its veins much distended ; and there is in some cases, but 
not in all, serous effusion into the sub-arachnoid tissue, and lateral 
ventricles. 

Nature of the disease. — It was for a long time supposed that 
cholera infantum was peculiar to this country, and widely different 
from any malady reigning amongst children in Europe. Its real 
nature was very imperfectly understood until within a few years, 
when the researches of Dr. Horner showed that it resembled very 
closely the follicular enteritis described by Billard in his work on 
children. Dr. Hallowell, in his recent and valuable paper, which 
I have so often quoted, gives it the title of endemic gastro-follicular 
enteritis, and regards it as a disease chiefly of the follicular appa- 
ratus of the digestive canal. After careful study of some of the 
most important European works upon the diseases of children, 
after close comparison of these descriptions with those given by 
our own authors, and with my own observations, I am led to the 
conclusion that cholera infantum or summer complaint is the same 
disease, with differences of frequency, severity, and fatality, as 
that described by Billard as follicular enteritis ; by Barrier as fol- 
licular diacrisis, apyretic, febrile, and complicated ; and by the 
authors of the Bibliotheque du Medicin Praticien under the title 
of " enteritis of children," including in that term inflammation, 
softening, diarrhoea, and diacrises. Rilliet and Barthez also de- 
scribe most of the symptoms and anatomical lesions of the disease 
in their chapter on inflammation and softening of the gastroin- 
testinal mucous membrane. Let me state, however, that though 
I believe cholera infantum to be the same disease as to its real 
nature as those just mentioned, it differs from them greatly in fre- 
quency, severity, fatality, and in the circumstance of a larger por- 



296 CHOLERA INFANTUM. 

tion of the gastro-intestinal mucous membrane being affected than 
is usual in the milder cases observed in Europe, in which smaller 
portions of that membrane are generally implicated. 

From the description of the anatomical lesions already given, it 
appears that the most characteristic and constant morbid altera- 
tions are development and ulceration of the follicular apparatus of 
the stomach and bowels. The mucous crypts are stated to have 
been much developed in the stomach only in one instance, and 
slightly developed in three. They were not ulcerated in any. In 
the small intestine they were more frequently affected, having been 
found numerous and distinct in two cases ; distinct only in the 
ileum in two, and only in the duodenum in one; and as slightly 
developed in nine. In two only were they slightly ulcerated. Of 
14 cases, therefore, in which their condition in the small intestine 
is mentioned, they were much developed only in two, and ulcer- 
ated in the same number. In the remaining cases, the alterations 
were slight, or observed only over a small part of the bowel, gene- 
rally in the ileum or duodenum. The agminated glands were 
natural in 6 cases, more developed than usual, and generally red- 
dened in 6, and not ulcerated in any. Of 12 cases, therefore, 
in which their condition is described, they were developed in 
half, and natural in the remainder. In the large intestine the 
crypts are stated to have been developed in all the 17 cases. In 
10 of these they were ulcerated, in 4 not ulcerated, while in the 
remaining 3 their condition as to ulceration is not mentioned. To 
recapitulate : the follicles are noted as having been developed in 
the stomach in three cases, as ulcerated in none ; in the small in- 
testine they were numerously developed in two cases, more slightly 
so in twelve others, and slightly ulcerated in two ; in the large 
intestine, they were developed in all, and of 14 in which their 
condition as to ulceration is mentioned, that lesion was noted in 10. 
It is clear, therefore, that the follicular disease is most constant 
and extensive in the large intestine, less so in the small bowel, and 
but seldom present in the stomach. 

As to inflammation of the mucous membrane, we found that of 
16 cases in which the state of the membrane was noted in the 
stomach, that lesion was present to greater or less extent, gene- 



NATURE. 297 

rally very slight in 6, while in 10 the tissue was pale and natural ; 
of 16 cases in which its condition is noted in the small intestines, 
it was found inflamed, usually in the duodenum or ileum only, 
in 7, while in 9 it was noted as pale; the condition of the mucous 
membrane of the large intestine as to inflammation is mentioned in 
15 cases, in 9 of which it was more or less inflamed throughout, 
in 2 the inflammation was confined to the rectum, in 4 it was 
slight. Inflammation was observed much the most frequently 
and extensively therefore in the large intestine, only half as fre- 
quently in the small intestine, and to a much slighter extent, and 
in a rather smaller proportion of cases in the stomach. 

Softening existed to a greater or less extent in the stomach, in 
10 out of 14 cases in which the condition of the mucous mem- 
brane as to that lesion was noted ; of 12 cases in which it was 
sought for, in the small intestines, it was present, in 5, slight in all, 
while the membrane was natural in the other 7 ; of 11 cases in 
which it was noted in the large intestine, it was present in 9, ab- 
sent in 1, while thickening existed in the remaining case. Soften- 
ing existed in the stomach and large intestine in about three-fourths 
of the cases, and in the small intestine in rather less than half the 
cases. 

As to the other abdominal organs, it was ascertained that the 
liver, which has been thought by many authors to play so great 
a part in the pathology of the disease, was much enlarged only in 
one case; and that the mesenteric glands, spleen, and kidneys 
were healthy. The brain, on the contrary, generally presented 
some injection of the membranes, and in most of the cases which 
proved fatal in the third stage, there was extensive disorganization 
of its substance from softening. 

For my own part, I am disposed to believe that cholera infantum 
is a disease of the mucous membrane of the alimentary canal, which, 
beginning with morbid development of the mucous follicles or 
crypts, independent of evident inflammation, occasions first super- 
secretions from those organs, and after a time runs into inflamma- 
tion and its results, ulceration, softening, and thickening. That it 
is not an inflammation in the beginning, is, it seems to me clear, from 
the nature of the anatomical lesions, and from the facts that the 



298 CHOLERA INFANTUM. 

early stage is often unaccompanied by any febrile movement what- 
ever, and is not unfrequently attended with disposition to collapse, 
like that which occurs in the cholera of the adult ; but that it be- 
comes an inflammation, after the development of the follicular 
apparatus has lasted a short time, is also, I think, apparent, from 
the nature of the anatomical lesions and from the circumstance 
that there is always more or less violent febrile reaction after the 
first few days. 

Symptoms. — The invasion of cholera infantum is extremely 
irregular in its mode of manifestation. It may be sudden or 
gradual. When sudden, the child is attacked with diarrhoea, 
while apparently in good health, and either simultaneously, or 
within a few hours, with more or less violent vomiting. I have 
known a child put to bed early in the evening, seemingly well, to 
wake at ten o'clock and have twelve large, fetid, fluid evacuations 
before morning, and then pass through a regular attack of the 
disease, lasting ten days. Much more frequently, however, the 
invasion is gradual, and the disease begins with slight diarrhoea, 
which makes its appearance after the child has shown unusual 
fretfulness, irritability, restless sleep, and some loss of appetite for 
one or two days. Most authors agree that the disease generally 
begins with diarrhoea, which after a few days or even longer time, 
is associated with vomiting. Of 20 cases that I have seen in which 
the mode of invasion was noted, it began with diarrhoea, and was 
associated with vomiting, in from two to five days after, in 11; 
in 3 the invasion was sudden, vomiting and purging coming on 
almost simultaneously ; in 6 there was no vomiting, or the child 
merely rejected doses of medicine which disgusted it. In sudden 
and violent cases, the vomiting and purging are attended with 
the usual signs of exhaustion ; quick, small pulse ; coolness or 
coldness, with paleness of the surface ; altered countenance ; ex- 
treme languor, and all the signs of severe illness. 

In slight cases there is no fever at first, and the child, though 
more peevish and irritable than usual, can be amused and diverted 
at times. In severer attacks there is often a febrile reaction from 
the beginning ; while in very violent cases, the earliest symptoms 
are those of collapse, which is generally soon followed by intense 



SYMPTOMS. 299 

heat of the head and body, very frequent, tense pulse, which sub- 
side after some hours, to give place to a more or less complete 
remission, or to a return of the state of collapse. 

As the diarrhoea is the most important symptom of the disease, 
it is necessary to trace its characters with as much accuracy as 
possible. The first change in the appearances of the stools is that 
they become more frequent, abundant, and fluid, than natural. 
They retain their homogeneous appearance, but change from 
the dark orange colour which they present in health, to a lighter 
yellow, like that of the yelk of egg, and begin to contain spots of 
a greenish colour. As the case goes on, the green tint generally 
increases, until the whole of the discharge is of that colour, so that 
it looks like chopped spinach. This is usually the predominant 
colour of the stools after the first few days. There is often mixed 
with the other materials constituting the discharge small whitish 
lumps, which are undigested portions of caseum. Sometimes they 
contain small quantities of fsecal matter also. Their consistence 
varies greatly, according to the stage, severity, and duration of the 
case. At first pasty and mush-like, they become after a time 
semi-fluid, with more consistent portions intermixed ; the fluid parts 
running through the napkins and clothes of the child, and leaving 

, merely yellowish and greenish, or whitish grumous particles upon 
the napkin ; while in other cases they are completely serous and 
leave no solid portions whatever upon the napkin. The odour is 
very characteristic in severe cases. It is excessively fetid, so as 
to render it almost impossible to cleanse the child from it, and 
making it often absolutely necessary to open the windows in order 
to get rid of it. I have known it so bad as to produce sickness of 

I stomach in a delicate person. It is impossible to describe it except 
by saying that it is putrefactive in character. This peculiar odour 
almost always coincides with copious watery stools, of a dark- 
brown colour. In other cases the odour is unpleasant, but much 

; less strongly marked, or it may be acid, or again the discharges 
may be entirely inodorous. The quantity varies greatly. In 
severe cases it is much more abundant than usual, and is some- 

i times very large indeed, particularly in the early part of the attack. 
At a later period the quantity is generally less, and sometimes 
amounts to a slight stain upon the napkin only. In some of the 






300 CHOLERA INFANTUM. 

cases the stools assume a dysenteric character, containing mucus 
mixed with blood in greater or less proportion, in addition to the 
matters above described. 

During the acute stage of the disease the child evidently suffers 
from pain in the bowels. This is shown by fretting, uneasiness, 
restlessness, and crying, for some time previous to a discharge, and 
by crying and sometimes violent screaming and tenesmic straining 
at the moment of the evacuation. This is particularly apt to be 
the case when the discharges contain blood or mucus, showing 
severe disease of the colon or rectum. 

The number of stools is generally about six or ten in the day, 
though in bad cases they may be much more frequent. I have 
rarely met with more than twenty or twenty-five as the highest 
number. 

The substances vomited consist of the contents of the stomach 
mixed with mucous and bilious matters. The frequency and vio- 
lence of the vomiting differ greatly, according to the severity of the 
case. Sometimes it is very distressing and frequent, so that every- 
thing is rejected as soon as taken, and with great violence ; at 
other times there is frequent retching and efforts to vomit, though 
there may be nothing upon the stomach ; while in other instances 
again it occurs only two or three times a day. It seldom continues 
to a great extent more than two or three days, after which it 
ceases entirely, or recurs only at long intervals, and particularly 
after the child has been allowed to take too much food or drink at 
one time. 

The disease is almost always accompanied by a febrile move- 
ment. The period at which this occurs, and its degree, depend on 
the severity of the attack. In bad cases, attended with much 
diarrhoea and occasional vomiting, it is almost always considerable, 
and sometimes violent ; whilst in those which are milder it seldom 
appears until some days after the invasion, and is slight. It is 
almost always of the remittent type, the exacerbation occurring in 
the afternoon and evening. In very mild cases there may be none, 
or it may consist merely of slight quickness of pulse, a little heat 
of skin, and unusual restlessness at night. The pulse in mild 
cases retains its regularity, and its volume and tension continue 



SYMPTOMS. 301 

natural. In severe cases it is quickened from the first, and as the 
disease progresses, becomes very frequent, rising to 130, 140, 150, 
or more, and is at the same time small, quick, and tense. It be- 
comes feeble, rapid, and sometimes intermittent, in cases threaten- 
ing a fatal termination. The skin is generally dry and warmer 
than natural at all times, and becomes hot during the exacerbation. 
The heat is not usually equal over the whole surface. In very 
slight attacks it often affects only the hands and feet, while in 
most of the cases the head and abdomen, particularly the latter, 
are the hottest parts, whilst the extremities, especially the in- 
ferior, are natural, or cool. In sudden and severe cases, the 
temperature of the whole surface often falls below the natural 
standard, and the extremities are so cold as to require artificial 
means to keep them warm. Under these circumstances the sur- 
face is always pale, and there is usually some moisture upon it ; 
the pulse is quick and feeble, the expression languid and exhausted, 
and there is indeed every sign of collapse. It not unfrequently 
happens that the state of collapse alternates with more or less 
violent febrile exacerbations, in which the surface regains its 
colour, the face becomes flushed, the skin hot, and the pulse fuller, 
stronger, and less frequent. The respiration varies according to 
the degree of the reaction. It rises to 40, 50, or 60. Dr. Hal- 
lowell states that when over 30, it is more or less interrupted. 

The countenance is scarcely altered in slight cases or in the 
early stage of any. As the disease increases it becomes anxious 
and distressed, and is flushed during the exacerbations, and pale in 
the remissions. In sudden and severe attacks it is exceedingly 
languid and subdued, pale, and contracted ; in protracted cases the 
features become thin and shrunken, the eyes are inanimate and 
sunken, the skin hangs in folds about the face, and the lips are 
thin, dry, and fixed. The nervous system reveals by various 
symptoms that it is more or less disturbed in its functions. At 
first the temper only is changed. The child becomes irritable, 
peevish, and cross, and cries or frets at the least contradiction or 
without cause. The sleep is restless and disturbed from the first, 
especially during the nights. The child wakes frequently, and 
almost always with crying; when asleep, its eyes are often 

26 



302 CHOLERA INFANTUM. 

but half closed, the brow is contracted and frowning ; it turns and 
twists, and moans or cries out as though in pain or distress. To- 
wards the termination of fatal cases drowsiness or stupor are very- 
apt to take the place of jactitation. 

The appetite is diminished in mild, and entirely lost in severe 
cases, except in children at the breast, who sometimes nurse with 
avidity, probably from thirst. The thirst is generally intense, espe- 
cially when the febrile reaction is considerable. In some few cases, 
however, it is not present. The mouth is usually warm, and the 
tongue moist at first, and coated with a whitish, yellowish, or 
brownish-yellow fur. Later in the disease the tip and edges be- 
come red, and in chronic cases the whole tongue often acquires a 
dry, red, smooth, or polished appearance. In those which tend to 
a fatal termination it often becomes dry and incrusted, and is some- 
times covered with aphthae. 

The abdomen is rarely tumid or tender to the touch in the be- 
ginning, except when the disease is very severe, and the invasion 
sudden. At a more advanced stage it almost always becomes 
tympanitic and tense, and sometimes, though not always, when 
carefully examined, is found painful on pressure. It is evident in 
most cases of any severity, from the drawing up of the inferior 
extremities, the twisting and turning of the trunk, and the crying 
of the child, that the evacuations are attended with more or less 
pain. 

Unless the attack be very slight and of short duration, there is 
always manifest emaciation. When the disease is grave the ema- 
ciation makes rapid progress in a very few days ; and in slow, 
tedious cases, it is one of the most marked symptoms. The skin 
under these circumstances is dry and harsh ; it assumes a wilted 
appearance, and hangs in folds about the neck, and especially over 
the internal surfaces of the thighs. The emaciation is sometimes 
excessive, — as great it seems to me, as in any other disease. 
About the time that the excessive emaciation described takes place, 
there often appears oedema of the feet, and sometimes a bloated 
condition of the face. Simultaneously with the emaciation and 
oedema, aphthee often appear on the tongue, cheeks, gums, roof of 
the mouth and pharynx ; the anus is excoriated by the acrid dis- 



DURATION DIAGNOSIS — PROGNOSIS. 303 

charges, and petechia sometimes make their appearance upon the 
skin, especially the parts on which the patient rests. The fatal 
event is almost always preceded by symptoms indicating violent 
disease of the brain. These are drowsiness, passing into stupor 
and coma ; chewing motion of the under jaw, or, as I have several 
times witnessed, a disposition to rigid contraction of that part ; 
rolling of the head from side to side ; and convulsions, either gene- 
ral or local, which are followed by rigidity or paralysis of some of 
the limbs, or by irregular automatic movements of different parts 
of the body. 

The duration of cholera infantum is exceedingly uncertain. 
Dr. Eberle(Zh"s. of Children, p. 285,) says it sometimes runs on 
to a fatal termination in five or six hours. The most rapidly fatal 
case that I have met with lasted nine days. It often continues for 
weeks or even months. It is not uncommon for a child to be 
seized with the disease in June, and continue more or less sick 
until the following October, or November, and in some few instances 
it continues to have diarrhoea, from functional derangement of the 
bowels, or entero-colitis, the greater part of the winter. The 
attack is very apt to last two or three weeks, until some change 
in the weather occurs, or the residence of the child is changed. 

Diagnosis. — The diagnosis of cholera infantum requires no par- 
ticular elucidation. The season at which it occurs, the age of the 
patient, the concomitance of vomiting and purging, the nature of 
the evacuations, and the course of the affection, render it easy 
of recognition. I have already stated that I believed the disease 
to be at first, a simple choleratic irritation of the digestive tube 
which rapidly passed into inflammation or entero-colitis, if the 
attack continued a few days. What gives to the disorder its pecu- 
liar features in this country, in the summer season, is, in all pro- 
bability, the severe and long-continued heat of the weather. 

Prognosis. — It is evident from the remarks made upon the fre- 
quency of the disease, in which it was stated that, with the exception 
perhaps of convulsions, it was the most fatal of all the affections of 
childhood, that cholera infantum is a very serious malady. The 
prognosis in any particular case, however, must be determined by 
a reference to several different circumstances ; of which the most 



304 CHOLERA INFANTUM. 

important are : the hygienic conditions in which the child is placed ; 
the age and period of dentition at which the disease occurs ; the 
present state of health ; and the existence or non-existence of 
hereditary predisposition. 

Children whose parents are placed in circumstances of life such 
as to secure to the former favourable hygienic conditions ; who 
can leave the city for the country when such a change is deemed 
necessary ; who reside in large well-ventilated houses in a good 
quarter of the city ; who can afford the time and money necessary 
to procure whatever is deemed desirable (not to say necessary,) for 
the patient, have, doubtless, a vastly better chance of recovery than 
those in opposite conditions. One of the most unfavourable cir- 
cumstances for the child, is the fact of its having been weaned at 
a very early age, or fed on artificial diet from birth. This, I be- 
lieve, increases the danger to a very great extent, and yet, even 
here, much may be done by a wise system of dietetic management, 
together with the removal to a proper atmosphere, or change from 
place to place. 

Cases occurring in very young infants, or early in the process 
of dentition, are more unfavourable than under opposite circum- 
stances, because of the greater mobility of the nervous system 
early in life, and of the longer continuance in action of the pre- 
disposing cause, dentition, which will tend to keep up the disease. 
Children already in feeble and deteriorated health from any 
cause, are more likely to die than those who are strong and well. 
Lastly, those who belong to families in which the disease has fre- 
quently prevailed, and especially in which it has proved fatal to 
other children, are in greater danger than where the opposite ob- 
tains. 

I have no statistics as to the proportional mortality, except the 
meagre statement that of 2-4 well-marked cases under two years 
of age that I have observed in private practice, two were fatal. 

The prognosis may be stated in general terms to be unfavourable 
in proportion to the frequency and violence of the vomiting ; the 
number of the stools ; the severity of the fever ; and the more or 
less marked character of the collapse. When the discharges con- 
sist merely of serous fluid and are copious and frequent ; when 



PROPHYLACTIC TREATMENT. 305 

they consist of small quantities of deep green matter mixed with 
much mucus or with blood ; when accompanied by straining ; 
when they number from fifteen to twenty-five in the day ; when 
they are very fetid ; and when with these symptoms, the abdomen 
is tense and tympanitic, the countenance pinched, the expression 
languid, the extremities cool, the pulse rapid and small, and the 
child irritable and restless, or on the other hand very still and sub- 
dued, the prognosis is exceedingly bad. If, after the symptoms 
just enumerated, drowsiness or stupor, and then coma, convulsions, 
rigidity, or paralysis, make their appearance, there is scarcely a 
hope left. 

The favourable symptoms in a case are : diminution of the 
fever ; equal temperature of the whole surface ; cessation of vo- 
miting ; decrease in the number of the stools, and a return to 
their natural colour, consistence, and odour ; quiet, tranquil sleep ; 
return of appetite ; and lastly, a restoration of the natural temper 
and gaiety of the child. 

Treatment. — Prophylactic treatment. — The danger to which 
teething children are exposed from residence in this city during 
the hot months of the year, is now so well understood, that nearly 
all parents who can afford and make it at all convenient, remove 
to the country during the warm season, and by this course very 
generally avoid the disease. It is undoubtedly the best plan that 
can be adopted, and very commonly succeeds. When it cannot be 
done, however, the prophylactic treatment consists in the most care- 
ful attention to diet, dress, and exposure to the open air. If pos- 
sible the child should be kept at the breast until it has passed 
through its second summer, as there is but little danger from the 
disease after that period. If the weaning must take place prior to 
that age, it ought to be accomplished before hot weather begins, 
as a change from the breast to artificial food during the warm 
season is very apt to bring on the disease. If the child is weaned, 
the diet must be strictly attended to. Up to the age of ten months 
or a year, the food should consist almost wholly of milk containing 
arrow-root, rice, oatmeal, or some farinaceous substance in small 
quantity. A little plain chicken or mutton water, with rice boiled 
in it, or a piece of beef or chicken to suck, may be given occa- 

26* 



306 CHOLERA INFANTUM. 

sionally, but all vegetables and fruits should be strictly forbidden. 
After the age of ten months, some light soup and small portions 
of mutton, chicken, or very tender beef, minced very fine, may be 
given every day in addition to the milk food, which must still form 
the major part of the child's nutriment. Fruit of all kinds, all 
vegetables except rice and potatoes, and the latter are doubtful, 
ought to be carefully avoided until after the hot season has entirely 
passed away, or until the child has its full set of teeth. I have 
found the food prepared with gelatine, in the manner described at 
page 193, to answer better than anything else, for a large number 
of children to whom I have prescribed it. 

The dress ought to be arranged according to the heat of the day. 
It is the fashion in this city to keep young children clothed all sum- 
mer in thick flannel jackets and petticoats, and woollen socks. This 
is certainly too much for the hot days which so frequently occur in 
July, August, and early in September, and is often, I believe, very 
injurious. A light gauze flannel shirt is, it seems to me, the only 
woollen garment that need be worn during the warm season. On 
hot days a child should have only this, a muslin petticoat and 
frock, and the lightest possible socks, or none at all. If, as con- 
stantly happens in our climate, a cool day comes, there should be 
added to these a light flannel petticoat. 

It is of the utmost importance that children should pass as 
large a portion of the day as possible in the open air. In the 
country this is easily managed, and parents almost always con- 
trive to accomplish it ; but in a city, many people seem to think 
it of less importance, or their servants are occupied with other 
things, and it is neglected. It is nevertheless a matter of the 
greatest consequence ; the child ought to be kept in the air by the 
nurse a large portion of the day ; either in the garden attached to 
the house, if there be one, at the front door, walking the streets, 
or, better still, making little excursions into the neighbouring 
country, taking care, however, to avoid the intense heat of the sun 
during the middle of the day. 

I believe that with constant and wise attention to these points, 
diet, dress, exposure to the air, and exercise, much may be done 






TREATMENT. 307 

in the prevention of the disease even in families obliged to remain 
in the city during the summer. 

Hygienic treatment. — As soon as a child, residing in a city, is 
attacked with cholera infantum during the hot season, it ought to 
be removed, if possible, to the country. If this cannot be done, 
arrangements should be made that will allow of its being carried 
into the air during the cooler parts of the day, either in the arms, 
in a carriage, or by making excursions into the neighbouring 
country. If there be extreme exhaustion or frequent vomiting, 
riding every day is too fatiguing, and we must rest satisfied with 
carrying the child through the house, or into the garden on a pil- 
low, making it a rule in the former case to have the windows open 
as much as possible, to secure a good ventilation. If the patient 
surmounts the violence of the attack, but continues to suffer from 
diarrhoea, loss of appetite, and emaciation, and remedies fail, after 
a trial of some days, to have any effect, we ought to insist upon a 
removal to the country, pointing out to the parents the very great 
probability of a fatal event, if this step be not taken. I believe 
that the best air for children in this condition is that of the sea- 
side. I have frequently known the most surprising recoveries to 
take place after a removal to the sea -coast, and they often occur 
with wonderful rapidity. I may state, moreover, my belief that 
the sea-coast is by far the best place to which to take children to 
pass the summer, for the purpose of avoiding the disease. I have 
rarely known cases to originate there, though this happens occa- 
sionally in the country. 

The diet must be strictly and attentively regulated day by day. 
If the child is still at the breast, it ought, if the nurse have enough, 
to be confined entirely to it. Nothing else should be given except 
cold water from time to time to slake thirst. If the child has been 
recently weaned, the wisest course to pursue is to procure a wet- 
nurse at once. When, on the contrary, it is fed wholly or in part 
upon artificial food, the regulation of the diet is decidedly the most 
important point in the treatment. The choice of food must depend 
in some measure upon previous habits. It may be stated, how- 
ever, in general terms, that the food ought to consist at least in 
part of milk or cream ; a wholly farinaceous diet, as I have so 



308 CHOLERA INFANTUM. 

often said, being, as a rule, unsuitable and injurious to the diges- 
tive organs. The diet that I prefer is the gelatine food already 
described, made with a small proportion of milk ; for, though a 
child may be able to digest, when in good health, pure cow's milk, 
or milk weakened with a third or half water, it will often fail to 
do so when the digestive power of the stomach is diminished by 
disease. I would therefore recommend only a fourth, fifth, or 
even sixth part of milk, with a very small quantity of cream, to 
be added to the solution of gelatine. To this, arrow-root may be 
added in the proportion of a teaspoonful to a pint of the fluid. If, 
as sometimes happens, the child cannot digest milk, we may try 
cream one part, to water four, five, or six parts ; or we may allow 
a little chicken, or mutton water, in which a small quantity of rice 
has been boiled, and afterwards strained out ; or rennet whey may 
be given, and when the child is very weak, wine whey with the 
addition of arrow-root water. As the disease subsides, or when 
the appetite is very bad, the patient may be allowed, with advan- 
tage, a piece. of ham, chicken, or under-done beef to suck. During 
the height of the attack it is important to regulate as well the 
quantity as the quality of the food. This ought to be much less 
than in health, even should there be a disposition to take as much, 
which is seldom the case. When vomiting is frequent, and espe- 
cially when obstinate, I have often found it necessary and use- 
ful to restrict the quantity to a very small amount, for instance, a 
tablespoonful, or even a teaspoonful, to be given only every half 
hour or twenty minutes, until the sickness ceases, after which it 
may be gradually increased. In severe cases it is sometimes well 
to allow nothing but gum water, barley, or arrow-root water, given 
in the manner just mentioned, for one or two days, taking care 
always not to let the child become too much exhausted for want of 
nourishment. 

Therapeutical treatment. — It is evident, I think, from the cha- 
racter of the anatomical lesions, and from the nature of the dis- 
ease, that most cases begin as a simple irritation of the secretory 
apparatus of the gastro-intestinal mucous membrane, independent 
of evident inflammation. If this view be correct, the treatment, in 
the early stage should be simple and calculated to avoid any in- 



TREATMENT. 309 

crease of the already existing irritation. When the symptoms are 
those of simple diarrhoea, in which the stools are merely a little 
more frequent, abundant, and fluid than natural ; when there is 
little or no vomiting ; and when the constitutional symptoms con- 
sist of slight heat of skin and restlessness at night, with some 
languor and unusual irritability ; I have found that lancing the 
gums if they required it, careful regulation of the diet as to 
quality and quantity, the use of the tepid bath morning and even- 
ing, or sponging with tepid spirit and water, and the administra- 
tion internally of half a teaspoonful or a teaspoonful of spiced 
syrup of rhubarb, with one or two drops of laudanum on the first 
day ; to be followed by a similar dose, or the use of some astrin- 
gent remedy on the second day, will often remove the disease 
without its becoming aggravated. When, however, the attack 
progresses, and vomiting, with signs of entero-colitis and fever, 
make their appearance, the case requires other treatment than that 
just mentioned. 

Attention to the state of the gums is undoubtedly a most impor- 
tant point in the management of cholera infantum. It often hap- 
pens that a child will have an attack of the disease whenever the 
gum over an advancing tooth becomes very much swelled and 
tense, which shows the intimate connexion that exists in many 
cases between the process of dentition and the disease. The gums, 
therefore, must always be examined, and if found to be prominent 
over any of the teeth, and at the same time hard, shining, and hot, 
they should be freely incised. I am convinced that this operation 
is often of great service in relieving irritability and insomnia, and 
also in rendering the disease more tractable to remedies, by re- 
moving a very important predisposing cause. 

Baths. — The use of the warm and tepid bath, and of sponging 
with water and spirit, are important and beneficial elements in the 
treatment. In slight attacks, the tepid bath, used twice a day, has 
proved of great service in my hands. When there is severe fever 
with excessive jactitation, the warm bath should be resorted to 
twice or three times a day ; or we may employ the affusion bath 
of water at 98°, containing vinegar, in the manner to be recom- 
mended in the treatment of scarlatina. It is a good plan, when 



310 CHOLERA INFANTUM. 

the skin is very dry and hot, to lift the child immediately from the 
bath into a blanket which has been moderately warmed, when, by 
wrapping it up, we may often obtain a perspiration, followed by 
calm sleep. If the child be weak and exhausted by a tedious or 
violent attack, a warm bath to which half a pint or a pint of 
whiskey has been added, will be found a very soothing and re- 
freshing application. When the use of the bath alarms or annoys 
the child so much as to produce violent agitation, it is better to 
abandon it for a time, and substitute sponging with warm or tepid 
whiskey and water, two or three times a day. In cases of extreme 
exhaustion, also, sponging is to be preferred to baths. 

Purgatives. — The careful employment "of purgatives in the 
disease is recommended by many writers. The motives for their 
use are differently stated by different authorities ; some prescribe 
them with the view of emptying the bowels of vicious secretions, 
others of accumulations, others to stimulate the liver to greater 
activity, and some, especially the French writers on diarrhoea, 
enteritis, and follicular diacrises, to modify the mode of action of 
the secretory apparatus of the intestinal tube. M. Legendre (Loc. 
cit. p. 672) says : " We entirely agree, therefore, with M. Gendrin, 
who regards emetics and purgatives as the most efficacious reme- 
dies in the treatment of the intestinal diacrises." For my own 
part I have generally employed them with care at some period of 
the disease, but feel convinced that they are capable of doing great 
injury when too freely or incautiously used. I believe that the 
proper moment for their administration, is at the beginning of the 
attack, when we have reason to suppose that the bowels may con- 
tain the products of an imperfect digestion, an accumulation of 
vicious secretions, or, whenever, in the course of the disorder the 
stools are observed to be partially consistent, dark-coloured, and 
very offensive. I think that in the latter condition of things they 
are very useful, particularly when preceded by several minute 
doses of calomel repeated every hour. When, on the contrary, 
the stools are copious and watery, or of a deep-green colour, 
mixed with a great deal of mucus, and accompanied with tenes- 
mus and crying, I believe that they tend to aggravate the symp- 
toms. The only purgatives which I venture to employ are rhu- 



TREATMENT. 311 

barb, magnesia, castor oil, and calomel. Of these, I prefer in the 
majority of cases, rhubarb in the form of the spiced syrup, of which 
a teaspoonful, or if the dose is to be repeated the same day, half 
a teaspoonful, guarded with half a drop or a drop of laudanum, 
is a proper quantity. If it be desirable to give a more speedy 
and active laxative, castor oil is preferable. Of this a teaspoonful 
is as much, I think, as ought to be given in a single dose, and 
very often half the quantity is fully enough. When there are 
signs of acidity of the digestive organs, magnesia is the best pur- 
gative. From a quarter to half a teaspoonful is enough for a dose. 
Calomel is highly recommended both as a purgative and alterative 
by many different authors. The dose varies between a quarter or 
half-grain, and two or three grains repeated every two, three, or 
four hours, until its effect on the bowels becomes manifest. My own 
opinion is that such doses are too large for young children, except in 
acute inflammatory diseases, and that they are apt to aggravate the 
existing irritation of the digestive mucous membrane. Moreover, 
it seems to me that such doses of a remedy acknowledged to be a 
powerful sedative, cannot be proper in a disease which frequently 
occasions symptoms of great exhaustion, or even collapse. From 
personal experience, therefore, I am disposed to believe that it is 
better not to use calomel in purgative doses as a general rule, but 
to exhibit it in very small quantities, and follow it by some laxative, 
as for instance, syrup of rhubarb or castor oil. The manner in 
which I prescribe it is to give a tenth or sixth of a grain, with a 
quarter or sixth of a grain of Dover's powder, every hour or two 
hours, until half a grain or a grain has been taken, after which I 
prescribe a small quantity of rhubarb or castor oil, and pursue the 
same treatment the next day, or the day but one after. Employed 
in this way, I have seen it of great service in correcting the dis- 
charges when they have been of a dark brown colour and very 
offensive, and sometimes when green and mucous. Dewees [Dis. 
of Children, p. 421,) says he has never found " temporizing reme- 
dies, as the alkalies, the absorbents, or external irritants, of the 
smallest service, we, therefore, never employ them." As soon as 
the stomach is tranquillized, he resorts to minute doses of calomel, 
giving as the average quantity a quarter of a grain every hour, 



312 CHOLERA INFANTUM. 

until the bowels are decidedly operated upon, which " may be 
known, by the stools being more copious, less frequent, and of a 
dark green colour, with a tenacious slime of the same or nearly 
the same tint of colour." After this the doses are given less fre- 
quently ; once in two, three, or four hours. A larger dose of 
calomel, two or three grains, may sometimes be exhibited with 
advantage when the constitutional symptoms are violent, and par- 
ticularly when there are signs of severe cerebral irritation early in 
the attack. I have seldom found it useful to continue the calomel, 
in whatever dose employed, more than two or three days. 

Antiphlogistics. — Dewees remarks that if there is " much fever, 
with great gastric distress, we have found the most decided advan- 
tage from bleeding, or the application of leeches over the region of 
the stomach ; or if there be much cerebral determination, we bleed 
from the arm, or draw blood from the temples by leeches." He 
recommends caution however in the use of depletion, and says 
he never employs it during the decline of the disease. Eberle 
says that when the abdomen is tumid, tense, and tender to the 
touch, and the pulse frequent, contracted, and quick, depletion 
ought to be resorted to either by venesection or leeches to the epi- 
gastrium. He thinks this ought to be done promptly and efficiently 
when the above symptoms are present. Dr. Condie recommends 
leeches to the epigastrium when there is increased heat of skin, 
when the patient appears to suffer much pain, and when the abdo- 
men is tumid and tender to the touch. Leeches to the epigastrium 
are recommended also by Dr. Wood, (Pract. of Med. vol. i, p. 
677,) when there is much tenderness of the abdomen, and the 
patient is not much exhausted. The same author advises a resort 
to local and general depletion, carried as far as circumstances will 
permit, when symptoms of meningeal inflammation occur early in 
the disease. M. Bouchut (Loc. cit.) opposes the employment of 
antiphlogistics in entero-colitis, except in some rare cases attended 
with strong febrile reaction and turgescence of the general capillary 
system. The authors of the Bibliotheque du Med. Prat. (t. v, p. 
674,) state that antiphlogistics are now almost entirely abandoned 
in the treatment of the enteritis and diacrises of children. Dr. Hal- 
lowell {Loc. cit.) speaks strongly of the importance of the anti- 



TREATMENT. 313 

phlogistic treatment, " instead of the purgative plan usually pur- 
sued and with such fatal results." He recommends venesection, 
or when the state of the pulse contraindicates it, leeches or cups 
to the abdomen. 

I have seldom made use of depletion in the treatment of the 
disease, having been deterred from it in severe cases by the dispo- 
sition to exhaustion and collapse, and in mild cases, by the belief 
that it was unnecessary. The cerebral symptoms which occur 
in the early shape, and which seldom consist of more than great 
excitement, restlessness, and irritability, have usually subsided 
without difficulty under the use of warm or tepid baths, revulsives, 
or mild laxative doses ; whilst those which occur towards the close 
of the fatal cases, and for which I have employed leeching on 
several occasions, have never been benefited by the remedy. In 
fact I am disposed to believe that the cerebral symptoms are of 
the same nature exactly as those described by M. Barrier, (Loc. cit. 
t. ii, p. 56-7,) as occurring in the follicular diacrises, of which 
he says, after stating that they more or less simulate meningitis, 
" On the whole, we are of opinion, from our researches, that they 
rarely depend upon intracranial inflammation ; that, under other cir- 
cumstances, especially when a slow and chronic mucous fever has 
occasioned great general debility, the serous diathesis, or anasarca, 
they may be the result of serous effusion into the ventricles or cavity 
of the arachnoid, and that they then constitute true hydrocephalus, 
a malady in which inflammation plays but a minimum part in the 
production of the phenomena. The only condition in which hydro- 
cephalic or phlegmasial irritation seem to us at all common, is that 
in which there exists difficult dentition capable of determining a true 
and active sanguine congestion towards the head, and this coinci- 
dence of difficult dentition with gastro-intestinal diacrises is not 
rare, as is well known. But the cases are still more numerous in 
which the encephalic symptoms are of a purely nervous nature, 
not to be attributed to inflammation or active dropsy, and leav- 
ing no traces in the nervous centres when these are examined 
after death." If this view of the nature of the cerebral symptoms 
attendant upon the gastro-intestinal affections of children be cor- 
rect, it would lead us to the opinion that antiphlogistics can seldom 

27 



314 CHOLERA INFANTUM. 

be necessary in their treatment, and such, as I have already stated, 
is the conclusion at which I have arrived from experience. When, 
however, they are accompanied by hot and flushed skin, with 
strong and active pulse, it would no doubt be proper to direct the 
application of leeches to the temples or behind the ears, of cold to 
the head, of a blister to the nucha, of revulsives to the extremities, 
and to make use of laxatives. 

Revulsives are recommended by Parrish, Dewees, and Eberle, 
when the temperature of the surface is unequal ; for the relief of trou- 
blesome vomiting ; and when there is decided determination of blood 
to the brain. Dewees and Eberle recommend the application of a 
blister over the epigastrium when there is troublesome vomiting, 
and upon the extremities when they are cold, and when the cere- 
bral symptoms are threatening. Dewees remarks that they usually 
promote perspiration, and adds : " It is a fact not sufficiently 
known, that without vesication, in certain conditions of the skin, 
diaphoresis will not take place." Eberle recommends the applica- 
tion of a blister behind the ears, or to the back of the neck, in 
the treatment of the disease, and says he has been much more 
successful since the adoption of this plan, than previously. He 
was led to the employment of this method by the example of Dr. 
Parrish, who began it from observing that infants who have the 
eruption behind the ears, so common during dentition, generally 
enjoy " an exemption from those dangerous disorders incident to 
this critical period of life." 

I have commonly resorted to revulsives under the circumstances 
above mentioned, and have almost always used mustard in the 
form of sinapisms, poultices, or pediluvia. When vomiting is 
very troublesome, a mustard plaster, or better still, a poultice 
made of two parts of Indian meal and one of mustard, applied 
over the abdomen for fifteen or thirty minutes, is a most excellent 
remedy. This may be repeated with great propriety in two hours, 
if necessary. Sometimes a spice plaster, made of different kinds 
of aromatics, as powdered cloves, cinnamon, and capsicum, half 
an ounce each, with enough flour and wine to make a poultice, 
and applied hot over the epigastrium ; or one made of cloves, 
nutmeg, ginger, and hot wine or water, and used in the same way, 



TREATMENT. 315 

answer an excellent purpose under the circumstances referred to. 
When the extremities are cold, and the child weak and exhausted, 
the use of sinapisms, hot pediluvia, or frictions with dry mustard, 
have proved very useful in my hands. I have never employed 
blisters except in cases attended with threatening cerebral symp- 
toms, and then I have almost always directed a small one to be 
applied to the nucha, taking care not to leave it in place more than 
one and a half or two hours, lest it might produce sloughing. I 
have never, however, known them to prove of essential service, 
except in the early stages of the disease. When the cerebral 
symptoms come on late in the attack, and consist of convulsions, 
rigidity, or paralysis, I believe blisters rarely or never do any good. 

Opiates. — Eberle, in speaking of opiates, says that the use of 
opium is, in general, highly improper in the early stage. With 
this I entirely agree, so long as there is severe fever and cerebral 
irritation ; but when the stools are frequent, the child very uneasy 
and restless, and the discharges accompanied with pain, and espe- 
cially when there is but little fever, while a disposition to coolness 
of the skin and exhaustion are manifest, from the violent onset of 
the disease, I believe that minute doses of opium, either in con- 
nexion with a laxative, with calomel, or by enema, prove a very 
useful and powerful curative means. I almost always resort to 
opium under these circumstances, making use of laudanum or 
paregoric, if it be given with syrup of rhubarb or castor oil ; of 
Dover's powder, if with calomel ; or of laudanum, if by injection. 
The dose of the opiate ought to be carefully graduated to the age 
of the child, and severity of the attack, being guided under the 
latter circumstances especially, by the degree of pain and restless- 
ness. It ought to be such as to tranquillize, it seems to me, rather 
than produce deep or long-continued sleep. 

After the febrile stage of the disease has passed away, and par- 
ticularly when there are signs of sub-acute entero-colitis, or dysen- 
tery, opium is, in my opinion, one of the most important remedies 
at our command. It may be used either per orem, or by injection ; 
and should be administered twice or three times a day. From 
one to three drops of laudanum may be given by injection, under 
the age of one year, or half a drop to two drops per orem ; or 



316 CHOLERA INFANTUM. 

from two to six or eight drops of paregoric in the same manner. 
A very excellent form of opiate to employ, is the Dover's powder, 
alone or combined with chalk, or acetate of lead. Of this I gene- 
rally give from a quarter to half a grain three or four times a day. 
M. Bouchut remarks (Loc. cit. p. 229) that opiates are very much 
depended upon by the Germans, and quotes Hufeland as asserting 
that opium is " of all remedies the one which promises the greatest 
certainty." 

Astringents. — Both Dewees and Eberle oppose the use of this 
class of remedies in the early stage, as injurious. After the 
symptoms of reaction have somewhat subsided, and the remedies 
proper in the early stages have been made use of, nearly all 
writers coincide in recommending astringents, for the purpose of 
diminishing the action of the secretory apparatus of the bowel, 
and of controlling the inordinate peristaltic action which is one of 
the chief causes of the frequent discharges. M. Legendre, who, 
as we have already seen, prefers the employment of emetics and 
purgatives in the early stage of the follicular diacrises, recom- 
mends, in cases in which these fail to give relief, the use of 
absorbents, astringents, and sedatives. M. Bouchut (Loc. cit.,) 
also makes use of astringents and tonics in the treatment of the 
diarrhoeas of young children. I am in the constant habit of re- 
sorting to them in acute and violent cases, so soon as I am con- 
vinced that the laxatives administered at the beginning have had 
some action upon the bowels, and after the use of calomel ; whilst 
in sub-acute cases in which diarrhoea is the most important symp- 
tom, and in most of the chronic cases, they, with diet and carefully 
regulated hygiene, form the basis of the treatment I have been in 
the habit of employing. 

The most important of those in general use are chalk, powdered 
crabs' eyes, kino, catechu, rhatany, and acetate of lead. The 
best are the chalk and crabs' eyes, in combination with astringent 
tinctures or opiates, and the aromatic syrup of galls. Their modes 
of preparation and doses are all given under the head of entero- 
colitis, to which place the reader is referred. The acetate of lead 
is recommended by Eberle, Chapman, and Condie. It may be 
given in doses of from a quarter of a grain to a grain every two 



TREATMENT. 317 

or three hours. Dr. Condie recommends it in doses of a grain, in 
combination with calomel, chalk, and ipecacuanha, to be repeated 
every three hours. I have used the sugar of lead in a very few 
cases, and am therefore unable to give an opinion as to its efficacy. 
We may also use with much benefit the nitrate of silver, both in- 
ternally and by enema, or the sub-nitrate of bismuth, or injections 
of extract of rhatany or tannin. The doses and modes of ad- 
ministration of these preparations have already been fully detailed 
in the article on the treatment of chronic entero-colitis. 

Tonics and stimulants. — It is often necessary to resort to these 
remedies in violent and in chronic cases of cholera infantum. 
When, for instance, in a sudden and severe attack, the patient falls 
into the state of collapse which so often accompanies the disease, 
the use of stimulants seems absolutely necessary. The one I prefer 
before all others is fine old brandy. Of this a teaspoonful may be 
put into a wineglassful or half a tumblerful of water, and the child 
made to drink of it from time to time ; or, from ten to twenty drops 
may be given every hour or two hours. If brandy cannot be ob- 
tained, or if it be strong and bad, old rum may be substituted, or 
very fine wine, or wine whey, either alone or mixed with arrow- 
root water. In chronic cases also, when the child is weak and 
languid, inattentive, and without appetite from long illness ; when 
the stomach seems to have lost in great part its digestive power, 
so that the patient not only refuses food, but often rejects by vo- 
miting in an undigested state, what was taken hours before, stimu- 
lants and tonics will be found of the greatest service. In some 
such cases I have been obliged to use a certain quantity of brandy 
three or four times a day for several days or even weeks in suc- 
cession. There need be no fear, it seems to me, of resorting to 
these remedies in cases marked by the above symptoms. I have 
never known them to do harm, and believe them to be often indis- 
pensable. Of the tonics, the best is probably quinine, in the dose 
of a quarter or half a grain three or four times a day, suspended 
in syrup. 

A very excellent stimulant is aromatic spirits of hartshorn, which 
may be given in doses of five or six drops every two or three 
hours. Eberle recommends tincture of cinnamon, in doses of 

27* 



318 DYSENTERY. 

fifteen or twenty drops in some mucilaginous fluid, every four 
hours. 

One of the most troublesome symptoms of the disease is vomiting, 
which is sometimes so obstinate and frequent as to be extremely 
exhausting. It is very important to relieve it on account of the 
prostration by which it is accompanied, and to enable us to admi- 
nister the remedies proper for the diarrhoea. Dewees says there 
is nothing so certain, or so prompt in allaying the sickness " as an 
injection of a gill of warm water, in which is dissolved a large 
teaspoonful of common salt ; this is for a child of a year old and 
upward, proportionably less for younger." He says it must be 
given no matter how frequent may be the discharges. I have 
never resorted to this plan, having always succeeded with other 
remedies which seemed less likely to irritate the bowel, and 
which, therefore, appeared to me preferable. I have generally 
found a hot mush poultice, a mustard poultice, or a warm 
spice plaster applied upon the abdomen, and the administration 
internally of iced brandy and water by teaspoonfuls, of lime water 
and milk, of minute doses of calomel, or of very small doses of 
some opiate, with the direction that the drinks and food shall be 
given only by the teaspoonful or tablespoonful for twelve hours, 
successful in arresting the vomiting however violent it. might be. 
Eberle recommends, under these circumstances, the application of 
a blister over the epigastrium ; while Dr. Condie speaks very 
highly of the following formula : R. — Aquae purse 3i ; Acetat. 
plumb, gr. v ; Acid, acetat. impur. fl^y ; Sacch. alb. pur. 3iii. — M. 
A teaspoonful to be given every hour or two, until the vomiting is 
suspended. 



ARTICLE IV. 

DYSENTERY. 

It seems to me unnecessary, after the long article on entero- 
colitis, to make more than a very few remarks on dysentery, 
which almost always exists in children in combination with inflam- 



CAUSES ANATOMICAL LESIONS. 319 

mation of the small intestine, constituting the disease already 
treated of under the title of entero-colitis. 

Dysentery is characterized by frequent evacuations, attended 
with more or less severe pain and straining, and consisting of 
mucoso-sanguinolent or sanguineous substances. 

The causes of dysentery seem to be but little understood, beyond 
the mere facts that it occurs as an endemic in some regions of 
country, and as an epidemic over large districts. It is frequent, 
also, as a sporadic disease, and in this form seems to depend upon 
the same causes as those already cited as productive of entero- 
colitis. It may be either idiopathic or secondary. As a secondary 
affection it is most apt to follow measles and variola. 1 have 
known dysenteric stools to occur in the course of cholera infantum, 
and in a considerable number of cases such as I have described 
under the title of entero-colitis. 

The anatomical lesions are confined chiefly to the large intes- 
tine, and are the same as those described under the head of entero- 
colitis, except that they are of a somewhat graver character. The 
mucous membrane is commonly found thickened, swelled, red, and 
softened ; the sub-mucous tissue sometimes presents ecchymosed 
points ; the follicles are often diseased, their orifices being enlarged, 
and ulcerated, as described under entero-colitis. In grave cases, 
particularly those occurring under epidemic influence, there are 
usually more or less extensive ulcerations, which may implicate 
only the mucous, or extend to the muscular or even peritoneal 
coat. In such instances, pseudo-membranes also are often formed, 
sometimes in large quantity, and often covering the ulcerations. 
The intestine contains sanguinolent mucus, sometimes a brownish 
or greenish material, evidently the result of a gangrenous condition 
of the mucous membrane, pus, and lastly false membranes. In 
some rare cases, perforation has been known to take place. 

Symptoms. — The symptoms are much the same as those already 
described as existing in entero-colitis, excepting that the local 
symptoms are more severe, and the presence of blood in the stools 
nearly constant. The disease often begins as a diarrhoea. The 
stools at first contain feculent materials, but after a time become 
very thin, small in quantity, and consist chiefly of mucus mixed 



320 DYSENTERY. 

with blood. The blood may be black and in considerable quantity, 
or of a dark rosy red colour, or like the washings of flesh ; it is 
mixed with greenish or yellowish substances, whitish mucus, 
fragments of false membrane, or purulent fluid. In young chil- 
dren there is evidently pain, from the restlessness, moving of 
the limbs, and crying about the time of the evacuations, while 
in those who are older, there is true tenesmus, like that ob- 
served in adults, and severe pain in the anus. The number of 
stools varies according to the severity of the case. There may be 
only four, eight, or ten in the day, or many more ; in one case of 
a girl six years of age, that came under my observation, there 
were between 40 and 50 in twenty-four hours. 

The abdomen is generally distended, tympanitic, warmer than 
natural, and painful. 

In mild cases there is usually no fever, or very little, while in 
severe attacks, there is high fever during the first few days, 
marked by frequent pulse, hot dry skin, followed, after a time, 
unless a favourable change take place, by coolness of the surface, 
contraction of the countenance, hollow, sunken expression of the 
eye, rapid emaciation, and death. 

It is useless to give a longer detail of the symptoms, as they are 
the same as those already described in the article on entero-colitis. 

The diagnosis presents no difficulties. The frequency of the 
discharges, the pain in the course of the colon and in the anus, the 
tenesmus, and the character of the evacuations, all make the dis- 
ease easy of recognition. 

The prognosis is favourable in mild cases, unattended with much 
fever, or very frequent discharges. When, on the contrary, there 
is violent fever in the beginning, followed by disposition to cool- 
ness and collapse ; when the stools are exceedingly frequent, and 
attended with violent pain and almost constant straining ; and 
when they consist of nothing but mucus, mixed with considerable 
quantities of blood, or with pus or false membranes, the prognosis 
is very unfavourable. 

Treatment. — The treatment should be much the same as that 
proper for entero-colitis. The only exceptions are that depletion 
by leeching in the early stage is more important, and that a freer 



TREATMENT. 321 

use of opiates by injection, or internally in combination with ca- 
lomel and Dover's powders, is necessary. Baths constitute an 
important part of the treatment, and should not be neglected. 
Warm poultices to the abdomen also are very useful. If opiates 
are given per orem in preference to by injection, the use occa- 
sionally of small demulcent injections will be found very soothing 
and beneficial. 

Nitrate of silver, and acetate of lead, particularly the former, 
often prove of great service in controlling the progress of the 
disease. For their doses and modes of administration, the reader 
is referred to the article on entero-colitis. 

The hygienic management should be precisely the same as that 
laid down in the remarks on entero-colitis. 



CLASS III. 

DISEASES OF THE NERVOUS SYSTEM. 

GENERAL REMARKS. 

It is a very common opinion both in and out of the medical 
profession, that this class of diseases occasions a much larger 
number of deaths in childhood than any other. Indeed, many per- 
sons suppose that, be the primary disease what it may, nearly all 
children who die, perish as it is said by the brain. It is clear, 
however, from the tables given by Dr. Condie, (Loc. cit. p. 86, 
88, 89, 90,) that they are very little more frequent than affections 
of the digestive organs, for it appears that the mortality in Phila- 
delphia under fifteen years of age, during the ten years preceding 
1845, from the former class was 6186, while from the latter it 
was 6068, being a difference of only 118. These two classes 
of disease constituted each about a fourth of the whole mortality 
under the age mentioned, whilst that from diseases of the respira- 
tory organs was nearly a seventh, and from measles and scarlatina 
combined rather more than a ninth. M. Barrier, whose observa- 
tions were made at the Children's Hospital in Paris, says [Loc. cit. 
t. i, p. 35), that, setting aside cases in which the nervous symptoms 
were probably only sympathetic of some other coincident disease, 
the cerebro-spinal affections were few in number in comparison 
with those of the thorax, abdomen, and senses, including amongst 
the latter the eruptive fevers. He states [Loc. cit. p. 34,) that 
affections of the thorax constituted two-fifths of all the cases of 
disease, those of the abdomen and senses each one-fifth, and of the 
nervous centres only a tenth. M. Barrier, after combating the 
opinion so generally entertained, that disorders of the nervous sys- 
tem cause the death of the greater part of the subjects who perish 



GENERAL REMARKS. 323 

before puberty, says (Lgc. cit. t. ii, p. 233) that there is only one 
circumstance which in part justifies this opinion, which he opposes 
" not. as false, but as exaggerated," which is, that the affections 
alluded to are almost always of a dangerous character, that they 
are beyond the resources of art, and that they furnish a very con- 
siderable relative mortality. He says that according to his expe- 
rience the mortality in diseases of the cerebrospinal system has 
been as sixty-eight in a hundred, whilst in those of the thorax, 
senses, (including the skin), and abdomen, it was respectively as 
forty-eight, forty, and thirty-two in a hundred. 

Before beginning the consideration of the particular diseases of 
this class, I am desirous of stating that I shall be compelled, on 
account of my limited space, to devote attention chiefly to those 
which are most important from their frequency or severity, avoid- 
ing or merely alluding to those which are of less consequence. 

I shall divide the whole subject into two classes, the first of 
which will contain all the diseases attended with, and dependent 
upon, some appreciable alteration of the nervous centres, while the 
second will contain those in which no such alteration exists. 
Amongst those belonging to the first division, I shall treat of tuber- 
cular meningitis first as the most important, then of simple menin- 
gitis, of cerebral congestion and hemorrhage, and of acute hydro- 
cephalus, by which I mean serous effusions in the brain independent 
of tubercular disease. Encephalitis or cerebritis, and induration 
and softening of the brain are of such rare occurrence in children 
as distinct and essential affections, that it is not necessary to treat 
of them separately. Amongst the diseases belonging to the second 
class I shall treat of several different convulsive affections, to wit, 
general convulsions or eclampsia, laryngismus stridulus or spasm 
of the glottis, idiopathic contraction with rigidity, and lastly, of 
chorea. 



CHAPTER I. 

DISEASES OF THE NERVOUS SYSTEM ATTENDED WITH APPRECIABLE 
ANATOMICAL ALTERATIONS. 

ARTICLE I. 

TUBERCULAR MENINGITIS. 

Definition; symptoms; frequency. — This disease is charac- 
terized by violent cerebral symptoms dependent upon the existence 
of tubercular granulations in the pia mater, as the essential anato- 
mical lesion ; and in the great majority of cases, by coincident in- 
flammation of that membrane, by softening of the central parts of 
the brain, by effusions of serum into the ventricles, and in many in- 
stances by tubercular deposits in other organs. Until within a few 
years tubercular meningitis, simple acute meningitis independent 
of tuberculization, and simple dropsical effusion within the cavity 
of the cranium independent of inflammation, have been confounded 
together under the single term of hydrocephalus or water on the 
brain. It has been shown of late, it seems to me, by the researches 
of the French observers, that a great majority of the cases of acute 
hydrocephalus of authors are, in fact, cases of tubercular menin- 
gitis. I am well aware that many of the English writers have not 
adopted this view of the pathology of these diseases, but neverthe- 
less, it seems to me, that the observations of Guersent, Gerhard 
and Rufz, Barrier, Rilliet and Barthez, Bouchut, and several 
others, have sufficiently proved that such is the fact. 

The term hydrocephalus ought to be, and indeed is at present 
by many, restricted to the disease whose essential condition is the 
existence of serum in some part of the brain independently of acute 
inflammation. It is scarcely necessary to state that the popular 



FREQUENCY. 325 

term " water on the brain," is applied to almost every acute case 
in children in which dangerous or fatal cerebral symptoms are 
present. 

There can be no doubt that this disease is one of rather frequent 
occurrence, though I am acquainted with no statistics excepting 
those given by M. Barrier, (Loc. cit. t. i, p. 34, 36,) which will 
enable us to form anything like an accurate conception upon this 
point. That author states that, during the period in which his ob- 
servations were carried on at the Children's Hospital in Paris, 
there occurred 576 medical cases of all kinds. In this number 
there were only ten cases of tubercular meningitis, whilst there 
were 83 of pneumonia, 48 of pleurisy, 24 of typhoid fever, 48 of 
measles, &c. &c, showing the first-named disease to be much less 
frequent than many other affections. We may also form some idea 
of its frequency in proportion to other diseases, by a reference to 
the work of Rilliet and Barthez, who report 33 cases of tubercular 
meningitis, against somewhat over 245 of pneumonia, 174 of bron- 
chitis, 111 of typhoid fever, 167 of measles, and 87 of scarlet fever. 
I am of opinion that it is not of frequent occurrence amongst the 
easier classes of this city, since I have met with only ten cases in 
private practice, in the course of six years. From what I have 
been told by other practitioners, however, it seems probable that it 
is much more frequent amongst the destitute classes, and particu- 
larly the blacks, who crowd the southern parts of the city, and 
suffer to a great extent from tubercular and scrofulous diseases. It 
is impossible to obtain accurate information in regard to the fre- 
quency of the disease in this city, in comparison with other affec- 
tions of the brain, from a reference to the bills of mortality, because 
of the fact that all or nearly all those affections are returned under 
the single title of dropsy of the brain. It may be stated, however, 
that it appears from the tables of mortality during the ten years 
preceding 1845, published by Dr. Condie (Loc. cit.), that there 
were 1906 deaths from dropsy of the brain under fifteen years of 
age, whilst there were 1592 from pneumonia, and 1172 from bron- 
chitis. Some of the cases returned under the title of dropsy of the 
brain were no doubt pure hydrocephalus, acute or chronic, others 
simple meningitis, and others no doubt different diseases in which 

28 



326 TUBERCULAR MENINGITIS. 

cerebral symptoms occurred at the fatal termination ; but a large 
number must have been instances of tubercular meningitis. 

Predisposing causes. — Rilliet and Barthez state that the disease 
is most frequent between the ages of 6 and 10 years, and then, 
in order of frequency, between 3 and 5, 11 and 15, and lastly 1 
and 2 years. The influence of sex has not been determined. It 
is clearly shown, I think, that a feeble constitution and the lym- 
phatic temperament act as predisposing causes, though on the other 
hand, it is also apparent, that it is not at all rare for children seem- 
ingly with every mark of robust and vigorous health, to be suddenly 
attacked with the disease. It is propagated also by hereditary in- 
fluence. It is not uncommon for several children in a family to 
die of tubercular meningitis. Under these circumstances, it has 
generally been ascertained that the parents, or some of the imme- 
diate relations, have either died with or shown unequivocal signs of 
tuberculous or scrofulous diathesis. It may follow other diseases, 
and has been observed particularly after measles and other febrile 
diseases, and after the suppression of eruptions. It has been 
shown of late, it seems to me, by the researches of the French 
observers, that a great majority of the cases of acute hydro- 
cephalus of authors are, in fact, cases of tubercular meningitis. 
I am well aware that many of the English writers have not 
adopted this view of the pathology of these diseases, but neverthe- 
less, it seems to me, that the observations of Guersent, Gerhard 
and Rufz, Barrier, Rilliet and Barthez, Bouchut, and several others, 
have sufficiently proved that such is the fact. 

M. Barrier (Loc. cit. t. ii, p. 379) explains, and I think with 
good show of reason, the causes of the disposition on the part of 
the tubercular diathesis in children to localize itself in the brain, 
and of the violence and extent of inflammatory action in propor- 
tion to the degree of the tubercular lesion, by the physiological 
conditions of the nervous system in early life, which are those of 
great functional energy, and nutritive activity. 

As to the exciting causes, nothing positive is known. The dis- 
ease has been supposed to be brought into action by falls and 
blows upon the head, by violent moral emotions, and by exposure 
to the sun. These causes, however, are all of doubtful influence. 



ANATOMICAL LESIONS. 327 

Anatomical lesions. — The tubercles, which constitute the essen- 
tial anatomical element of the disease, are very rarely found in 
the cavity of the arachnoid membrane, but almost invariably be- 
neath that tissue, or in the pia mater. They generally exist 
either as yellow granulations or as miliary tubercles. Gray gra- 
nulations are rare. They may exist separately or together in the 
same individual. The isolated yellow granulations are the most 
frequent of the forms of tubercle found in the meninges. They 
may commonly be seen scattered through the arachnoid, in the 
shape of small, yellow, flattened bodies, from two to four-fifths of 
a line in diameter, scarcely resisting under the finger. When the 
pia mater is torn off from the surface of the brain, other granula- 
tions which had been buried in the anfractuosities, come into 
view. These are rounded in shape, differing from those lying on 
the surface of the convolutions, which, as we have seen, are flat- 
tened from the pressure of the arachnoid. The size of the granu- 
lations varies Very much. They are sometimes so small, and so 
closely resemble in colour the surrounding parts, that it requires 
a careful search to detect them. They vary greatly also in num- 
ber, existing sometimes in the greatest quantity throughout the pia 
mater, whilst in other cases it is difficult to find more than one or 
two on each hemisphere. They are found on all parts of the sur- 
face of the brain, on the convex and internal surfaces of the 
hemispheres, on the lateral and middle portions of the base, in the 
fissures of Sylvius, and on the cerebellum. They are more nume- 
rous, according to Rilliet and Barthez, on the convex surface of 
the hemispheres, than at the base, but this is contrary to what 
has been asserted by most other authors ; they are more fre- 
quently met with upon the hemispheres than on the cerebellum. 
Wherever found, they may be either isolated at some distance 
from each other, or collected together into groups of greater or 
less extent. 

Miliary tubercles, which are not unfrequcntly met with, vary 
much in size, number, and arrangement. They vary in size from 
that of a hemp-seed to that of a pigeon's egg. Generally there 
are one, two, or three, about as large as a pea or small nut; if 
more numerous, there are seldom over fifteen or twenty, when 



328 TUBERCULAR MENINGITIS. 

they are usually about the size of a hemp-seed. Generally 
isolated, they are sometimes united into irregular masses, contain- 
ing portions of altered pia mater. They are more frequent on the 
convex surface than at the base of the hemispheres, and on the left 
than right hemisphere. They are rarely found in the fissures 
of Sylvius, or on the cerebellum. As the tubercle enlarges 
it becomes strongly united to the membranes, and these latter, 
owing to the presence of the tumour, become attached to the dura 
mater. Internally, the tubercle forms a depression in the sub- 
stance of the brain, into which it sinks deeper and deeper, until it 
is almost surrounded, preserving, however, its connexion with the 
pia mater. 

I shall next consider the lesions which coexist with tubercles 
of the meninges. The most important of these are inflammation 
of the membranes, and serous effusion into the ventricles. The 
chief seat of inflammation, as of the tubercular deposition, is the 
pia mater ; the arachnoid membrane being, as a general rule, 
affected only to a slight extent. That membrane sometimes, how- 
ever, contains a very small quantity of clear or turbid serum in 
its cavity. Its surface is often dry and viscid, and in some in- 
stances its whole tissue is opaque and thickened. But it is chiefly 
in the pia mater that are found the evidences of severe inflamma- 
tion. In order to detect these changes, it is necessary to examine 
the membrane, not merely upon the surface of the brain, but to 
tear it off, so as to bring into view the portions which dip in 
between the convolutions, and which often exhibit the greatest 
amount of morbid alteration. The inflammatory lesions vary be- 
tween mere vascular injection, infiltration with clear, turbid, or 
gelatinous liquid, and the most abundant suppuration. When the 
inflammation has gone beyond mere sanguine injection, it is 
marked by infiltration of the membrane with turbid, whitish, or 
sanguinolent serum, with pus, which may be liquid or concrete, or 
with whitish coagulated lymph. These products are most abundant 
at the base of the brain, about the peduncles of the cerebrum, and 
in the fissures of Sylvius ; on the convexity of the hemisphere 
they are more abundant on a line with the anfractuosities than on 
the summits of the convolutions. The pia mater, which in a 



ANATOMICAL LESIONS. 329 

healthy brain can be readily detached from the surface of that 
organ, becomes, in cases of meningitis, particularly those which 
are violent, more or less adherent, so that in tearing it off, portions 
of the cerebral substance come with it. The proper tissue of the 
membrane is thickened and indurated, the degree of thickening 
depending on the amount of infiltration. 

After the changes in the pia mater, the most important anato- 
mical feature is effusion within the ventricles. This was formerly 
thought to be the essential lesion of the disease, but recent re- 
searches have shown that it is absent in some instances which 
have followed in all respects the ordinary course of the malady. 
According to M. Barrier, effusion cannot be supposed to exist 
unless the ventricles contain from one and a half to two ounces of 
fluid, whilst Rilliet and Barthez assert that the normal quantity is 
a few grammes (about a drachm). The quantity is very variable ; 
sometimes there are only a few drops or a teaspoonful, while, in 
other instances it amounts to three ounces and a half, or much 
more. It may be so large as greatly to distend the ventricles, 
rupture the soft commissure of the thalami, and even the septum 
lucidum, diminish considerably the thickness of the hemispheres, 
and flatten the convolutions against each other. In such cases 
the effusion passes through the membrane of the ventricle, in- 
filtrates into and softens the substance of the brain, so that the 
latter becomes almost of the consistence of thick cream. The 
characters of the fluid vary in different cases. It is white, per- 
fectly limpid and transparent, or it may be turbid, either from 
being secreted in that condition, or from holding in suspension 
albuminous or purulent flocculi, or portions of the broken-down 
walls of the cavity. In some rare instances it is sero-sanguinolent. 
Barthez and Rilliet remark that the effusion which coincides with 
tubercular meningitis is different from that which accompanies 
tubercles of the brain. In the former it takes place rapidly, is 
turbid, and exists in smaller quantity, and constitutes acute hydro- 
cephalus. In the latter it is secreted slowly and in considerable 
quantity, dilates the walls of the cranium, and constitutes chronic 
hydrocephalus. 

The brain itself presents various morbid alterations. The whole 

28* 



330 TUBERCULAR MENINGITIS. 

organ often seems enlarged, so that the dura mater appears dis- 
tended, and when the latter is cut into, the cerebral substance pro- 
trudes in the form of a hernia. At the same time the convolutions 
are observed to be pressed against each other, and the anfractuo- 
sities seem to have disappeared. The compression of the brain 
depends either upon the distending action of the ventricular effu- 
sion, or upon sanguine turgescence of the organ. In most cases, 
but not in all, there is evident congestion of the cerebral substance, 
shown by more or less abundant dotted redness, and sometimes by 
general rosy tint of the medullary, and vivid redness of the cor- 
tical portion. Softening of the substance of the brain is of com- 
mon occurrence in connexion with the other lesions. I have 
already spoken of the softening of the walls of the ventricles 
when there is much effusion, and which appears to result from the 
macerating influence of the fluid. I have also referred, very cur- 
sorily, to the softening which exists under the inflamed portions of 
the membranes, and which occasions adhesion of the pia mater to 
the brain beneath. In the latter cases the softening may be either 
red or white, and does not penetrate more than a line, and often 
less, in depth. 

In addition to the changes already described, it is quite common 
to meet with tubercles of the brain itself, having no connexion 
with the meninges. They are found in various parts of the organ, 
and differ greatly in size, varying generally between that of a 
millet-seed and hazel-nut, but reaching sometimes the volume of a 
pigeon or hen's egg, or even that of half the fist. 

I have a few words to say in regard to the lesions of other 
organs. It is undoubtedly true that in the vast majority of cases 
tubercles are found in other parts of the body. Of aU the cases 
of tubercular disease observed by Rilliet and Barthez, amounting 
to 312, in only one was the deposit confined to the meninges. 
(Loc. cit., t. iii, note, page 49.) M. Valleix (Guide du Med. Prat. t. 
ix, p. 196, 197,) states that in all the cases, without exception, of 
tuberculization of the meninges in adults, tubercles exist also in 
the lungs, and that the same is true, in the vast majority of cases, 
in regard to children. The organs in which the deposit is most 



ANATOMICAL LESIONS SYMPTOMS. 331 

apt to exist are the bronchial ganglions, lungs, mesenteric glands, 
pleura, and peritoneum. 

Another very frequent lesion is softening of the stomach. 
This may affect only the mucous or all the coats, so that a slight 
degree of force will suffice to tear the organ. Dr. Gerhard ( Am. 
Journ. Med. Sci. vol. xiv, 1834), states that lesions of the stomach 
existed in six of the ten cases detailed by him, and in four-fifths of 
others not detailed. 

Before quitting this subject, I would call the attention of the 
reader to the fact mentioned by M. Valleix (Loc. cit. t. ix, p. 214), 
that all the symptoms about to be described as constituting the 
disease under consideration, with the exception of paralysis, may 
depend on simple tuberculosis of the meninges. Several cases 
have been cited, in fact, in which the only lesion found after 
death consisted of granulations in the pia mater. No traces of 
inflammation were observed. It is clear, therefore, that the evi- 
dences of the disease, or symptoms, depend not merely on inflam- 
mation caused by the tubercular deposits, but on the presence 
of that morbid production. The paralysis, which is one of the 
important symptoms, is thought to depend chiefly on softening 
of the substance of the brain. The author referred to states that 
it occupies the side opposite that in which the change exists. 

On the other hand, it also happens, that children die with all the 
symptoms of the disease, and after death, very few or no granu- 
lations are found to account for the inflammatory changes exist- 
ing in the head, but the tuberculous product is found in other 
organs of the body, thus establishing, I think, the true nature of 
the case. 

Symptoms,' course; duration. — The disease has been divided 
by authors into different stages, founded on the predominance of 
certain symptoms at particular periods of its course. 

These divisions are all imperfect and unsatisfactory, because the 
disease is in fact a continuous one, and for this reason some writers 
have avoided attempting any classification of the symptoms, [t 
seems to me, however, that we can obtain a more faithful picture 
of the disorder by adopting the division made by M. Valleix, which, 
though arbitrary and imperfect, because of the want of a natural 



332 TUBERCULAR MENINGITIS. 

line of demarcation seems warranted by the very great difference 
in the character of the symptoms at an early and late period of 
the affection. I shall therefore describe first the invasion of the 
malady, and then two stages or periods of the symptoms after the 
disease is confirmed. 

The invasion may be slow and tedious, or very sudden. In the 
majority of cases it is sudden, the child being attacked while ap- 
parently in good health ; while in a smaller number it occurs 
during the course of tubercular disease of other parts of the body, 
or after various symptoms of disordered health have existed for a 
considerable length of time. Whether slow or rapid it is marked 
by three important symptoms, headache, vomiting, and constipa- 
tion, to which is added in the great majority of cases slight accele- 
ration of the circulation. At the same time the intelligence of the 
child remains perfect, strength is not greatly diminished, appe- 
tite is not entirely lost, and thirst is moderate. These symptoms 
usually last but two or three days before others make their appear- 
ance, showing that the attack is confirmed. In some few instances, 
however, they last, with irregular intermissions, for several weeks. 
In one case, in a girl six years of age, that came under my notice, 
the invasion was preceded during three months by occasional 
cough, and irregular attacks of fever, by progressive emaciation, 
paleness, languor alternating with extreme irritability, disinclina- 
tion to take exercise, and during the latter part of the time by par- 
tial lameness, and in fact by all the signs of general tubercular 
disease. In another, which occurred in a boy eight years of age, 
it was preceded for several months by frequent complaints of in- 
tense headache, especially after taking active exercise, and by un- 
usual languor, but no other symptoms. The boy was sent to 
boarding-school apparently well and was suddenly attacked there. 
In another case the meningeal symptoms were developed in the 
course of phthisis, whilst in the remaining seven that I have seen 
the invasion was sudden. 

First stage.— The headache, vomiting, and constipation persist 
and become more marked. Headache is a nearly invariable 
symptom in children old enough to describe their sensations, and 
is therefore very important. In infants its presence is to be in- 



SYMPTOMS. 333 

ferred when the child frequently carries its hands to various parts 
of the head and presses strongly against it, and when the head 
is constantly rolled from side to side. It is generally frontal, and 
is usually referred to a point just over one or both brows. In 
other cases it extends over the whole head. It is commonly se- 
vere, so that the child when old enough complains of it spon- 
taneously. In the case of a girl seven years old whom I saw, it 
was so severe that she cried frequently and bitterly, begged to 
have the doctor sent for, and submitted willingly to any remedy 
suggested with a view to its relief. It is thought that the acute, 
shrill cry of the disease, to which the term hydrencephalic has been 
applied, depends on the acuteness of this pain. It usually lasts 
throughout the first stage, and ceases only as the delirium and 
coma of the second stage come on. Vomiting is also a nearly 
constant symptom. Of 80 cases, collected from different sources 
by M. Barrier, it was absent only in 15, or less than a fifth. This 
symptom generally makes its appearance on the first day, rarely 
later than the second or third, and lasts two or three days, and 
sometimes longer. In one case that I saw, it lasted eleven days, 
though it was but slight on the tenth and eleventh. The matters 
ejected from the stomach consist of the ingesta, and of mucus and 
bile in various proportions. It is commonly repeated two or three 
times a day. Constipation is even more important as a symptom 
than the one last named. Of 87 cases it was absent only in 7, 
according to Barrier. Rilliet and Barthez state, however, that it 
exists at the beginning only in about three-fourths of the cases. 
Where there is diarrhoea, instead of constipation, at the inva- 
sion, as sometimes happens, the former symptom almost always 
depends on tubercular disease of the intestine. Even under these 
circumstances, however, the diarrhoea is sometimes arrested and 
constipation substituted under the influence of the cerebral disease. 
The constipation generally persists obstinately for several days, 
and then gives way under the influence of purgative medication, 
or is replaced spontaneously by diarrhoea with involuntary stools 
towards the termination of the case. 

In connexion with the three important symptoms just described, 
there are others, which though less characteristic, are of much as- 



334 TUBERCULAR MENINGITIS. 

sistance in forming the diagnosis. The child is dull and sad, or 
excited and irritable by turns ; he shuns the light, or closes the 
eyelids and contracts the brows when it is thrown upon the face ; 
the sleep is restless and disturbed, and accompanied by grinding of 
the teeth ; and he utters from time to time, both sleeping and 
waking, the peculiar, shrill, sharp, and sudden scream, which 
seems to depend upon internal pain, probably headache, and which 
has been called by Coindet the hydr encephalic cry. The intellec- 
tual faculties remain undisturbed in the majority of the cases 
during the first few days, and this fact, which is so contrary to 
what might be expected, is one of the utmost importance in the 
judgment of the case. I remember being asked by the little girl 
seven years old, to whom I have already referred, " why it was 
that she saw double, why she saw two mothers and two doctors?" 
At the time when she first asked the question there was no per- 
ceptible strabismus, but on the following day, I thought I could 
detect a deviation of one of the eyes from its proper axis, and on 
the third day, the deviation was very marked ; though the poor 
child still wondered why she saw two objects instead of one. In 
another case, in a boy five years old, there was no disorder of the 
intelligence until the eleventh day, when there r was slight delirium 
alternating with somnolence ; yet it was clear from the first that 
the attack would prove one of tubercular meningitis, from the co- 
existence of violent frontal headache, obstinate vomiting, consti- 
pation, slow and irregular pulse, and the absence of other local 
or general symptoms. In only a fifth of the cases observed by 
Rilliet and Barthez was there perversion of the intellectual facul- 
ties at the invasion. Let us observe, moreover, that even when 
children present some of these disorders early in the attack, 
they generally consist only of slight delirium, dulness of the 
intelligence, slowness and hesitation in answering questions, dis- 
position to somnolence, excessive irritability and peevishness of 
temper, and what is more important and characteristic than any 
of these, perhaps, of a certain expression of the countenance, 
and particularly of the look, which is expressive of astonishment 
or of the utmost indifference. The look is in fact fixed or 
staring, like that of one in a mild ecstacy. Even when these 



SYMPTOMS. 335 

symptoms exist, however, at an early period, they not unfre- 
quently alternate with the most perfect clearness of the faculties, 
so that the physician in private practice, who sees his patient only 
at long intervals, and for a few moments at a time, should never 
venture to disbelieve without due consideration, the account of the 
mother or nurse as to their occasional presence during his absence, 
even though never observable during his visit. I knew this to 
happen in regard to a boy eight years old, whose mother con- 
stantly insisted to the physician in attendance, that during his 
absence the child occasionally presented slight delirium, and a 
wild uncertain expression of the countenance, which made her 
fear that his brain might be affected. As the child's intelligence 
was perfect, however, whenever the doctor saw him, he deter- 
mined that the mother was fanciful through over-anxiety, and 
ascribed the sickness to a bilious disorder of the stomach. After 
a few days the case developed itself, and the boy died with every 
symptom of tubercular disease of the brain. 

When disorders of intelligence do not occur in the early days 
of the attack, they usually make their appearance about or soon 
after the fifth day. 

During the first stage the coloration of the face ought to be noticed. 
It is generally paler than natural, though from time to time a sud- 
den flush of redness may be seen to pass over it. The condition 
of the senses is natural, except that the acuteness of the eye, ear, 
and sometimes that of touch, are exalted, so that the child avoids 
the light, starts at sudden or loud sounds, and cries when it is touched 
or moved. The respiration becomes unequal and irregular, and 
is interrupted by sighing or yawning. 

Convulsions rarely occur in the first stage. Rilliet and Barthez 
conclude that meningitis without complication of tuberculous disease 
of the cerebral substance, never begins with convulsions, and that, 
on the other hand, whenever they appear at the invasion, or occur 
frequently and with violence, they almost always coincide with 
tubercles of the substance of the brain. 

The tongue remains moist ; the appetite is not entirely lost ; 
thirst is moderate ; the constipation continues, unless removed by 
treatment ; the abdomen becomes retracted, so that its walls ap- 



336 TUBERCULAR MENINGITIS. 

proach very closely to the spinal column, and allow us to feel 
the pulsations of the aorta without using more than very slight 
pressure. The latter symptom comes on gradually and is gene- 
rally well marked by the sixth day or a little later. Rilliet and 
Barthez regard it as a very important sign, and state that they 
have observed it almost exclusively in cerebral affections. They 
think it depends not upon contraction of the abdominal muscles, 
but upon retraction of the intestines. I can add my feeble support 
to the evidence of the above authorities as to the value of this symp- 
tom. It has been very marked in the cases that I have seen. 

The state of the circulation is of the utmost importance in form- 
ing the diagnosis. So true indeed is this, that Dr. Whytt of Edin- 
burgh, whose description of acute hydrocephalus, published in 1768, 
has been most highly commended by all recent writers as a singular 
instance of accurate observation, makes three stages of the disease, 
each of which is characterized by the state of the pulse. In the 
early part of the attack the pulse is accelerated, rising to 110, 120, 
or, according to Whytt, in a few cases to 130 or even 140. At 
the same time it is neither full nor tense as a general rule, but 
rather soft and compressible. This condition of the pulse changes, 
as we shall find, in the middle period of the disease, and again 
shortly before the fatal termination. The heat of skin is usually 
moderate at this time, as might be supposed from the state of the 
circulation. 

Second stage. — This stage begins about the time that the more 
marked nervous symptoms show themselves. The headache gene- 
rally subsides or ceases at the beginning of this period and gives 
place to delirium. This occurs usually somewhere between the 
sixth and twelfth days. The delirium which occurs has been 
generally supposed to be always mild and calm. Rilliet and 
Barthez state, however, that in one third of their cases it was in- 
tense, and accompanied with cries, agitation, and frequent changes 
of position. In most of the. cases it is mild, and is manifested in 
older children by their muttering unintelligible words, by inatten- 
tion to what is going on around them, by an expression of wild- 
ness and astonishment, and by hesitating answers to questions. 
In children under two years of age there is no proper delirium. 



SYMPTOMS. 337 

There is, however, an analogous condition which is characterized 
by disorder of the two faculties of attention and perception. This 
symptom seldom lasts more than two or three days, and generally 
alternates with somnolence, so that the child is either dozing and 
sleeping, talking in its sleep, or frequently waking with loud cries 
and restlessness. It has often been asserted that general and special 
sensibility were very much exaggerated at some period of the 
disease. Rilliet and Barthez state, however, that in only four of 
their patients was the general sensibility exalted. Much more 
generally it is diminished in the early part of the second stage, 
or about the seventh day, and completely abolished towards the 
end. The face in the second stage is almost always pale, or pale 
and flushed alternately. Occasionally contractions pass over the 
features, giving rise to grimaces, after which the countenance re- 
sumes its expression of indifference and stupor. The eyelids are 
generally only partially closed, and between them the globes of the 
eyes can be seen to oscillate and move in various directions, as 
though by some automatic force. 

As the case progresses the nervous symptoms become more and 
more marked ; somnolence gradually deepens into coma ; the de- 
lirium becomes less and less frequent ; and the child no longer 
observes what is going on, nor answers questions. As the somno- 
lence and coma increase, various lesions of motility make their 
appearance, consisting, in order of frequency, of paralysis which 
is generally partial, contraction with rigidity of the limbs, stiffness 
of the trunk, spasmodic closure of the jaws, carphologia, subsultus 
tendinum, and convulsions. The paralysis is almost always partial 
and of very limited extent, affecting for instance, the jaw, the orbi- 
cularis muscles of the eyelids, the levator of the upper eyelid, the 
tongue or one side of the face. It is very rare to see one of the 
limbs paralysed. Contraction with rigidity of the muscles is an 
important symptom, but is not always present. When it exists it 
generally appears at an advanced period of the attack, commonly 
between the seventh and thirteenth days, and is usually partial. 
It may affect either the extremities, trunk, or inferior maxilla. It 
is seldom permanent, but after lasting one or two days, disappears, 
to reappear at a later period. The carphologia, subsultus, and 

29 



338 TUBERCULAR MENINGITIS. 

chewing motion of the under jaw generally occur only a few days 
before death, and last but one or two days. Rilliet and Barthez 
state that convulsions never occur at the commencement of menin- 
gitis, unless there be a complication of tubercular affection of the 
cerebral substance, and that they are rarely frequent or violent 
during the course of the case, except under the same circumstances. 
When they do occur in tubercular meningitis, they may be limited 
to the extremities, upper lip, eye-balls, or they may be general. 
Sometimes the child perishes in a convulsion. They are generally 
much less important as a symptom, according to M. Valleix, than 
in simple acute meningitis. 

The decubitus in the early part of the second stage is generally 
lateral, with the thighs flexed upon the pelvis, the legs upon the 
thighs, the arms applied against the thorax, the elbows bent, and 
the hands placed in front. At this time the child will still occa- 
sionally move its position with facility, showing that strength is 
not by any means entirely lost. At a still later period the decu- 
bitis is dorsal. In the latter part of the first, and early part of the 
second stage, the pulse, which we have ascertained to be accele- 
rated at the invasion, falls to the natural standard, or becomes 
slow, and at the same time irregular. From 110 or 120, as it 
was, it now sinks to 90, 80, 60, or, as happened in one instance 
to M. Guersent, to 48 in the minute. Coincidently with this change 
it almost always becomes irregular. The irregularity affects both 
its force and quickness, so that a strong pulsation may be followed 
by a feeble one, or the rhythm may be regularly or irregularly 
intermittent. The irregularity varies greatly at different periods 
of the day, or within short spaces of time, so that the pulse 
is found to be very slow at one moment and much more fre^ 
quent the next. On this account it is necessary to examine it on 
different occasions. Slowness and irregularity of the circulation 
are important as a means of diagnosis, since it has very rarely 
been met with as a permanent condition, except in the tuberculo- 
inflammatory affections of the brain and its dependencies. Towards 
the termination of the disease, generally speaking two or three 
days before death, the pulse rises again in frequency, so that it 
counts at first 112 or 120, and gradually increases to 140, 160, 



SYMPTOMS DURATION DIAGNOSIS. 339 

or even 200, the day before, or that on which death takes place. 
Simultaneously with this change it also becomes extremely feeble 
and small, and often ceases to be perceptible at the wrist on the last 
day. The lieal of skin increases with the acceleration of the pulse. 
During the last few days the surface is often covered with an abun- 
dant perspiration ; the tongue becomes dry ; the teeth and gums 
are fuliginous ; the exhaustion increases ; the respiration becomes 
stertorous, unequal, difficult and anxious, and at the very last 
attended with great dyspnoea ; and the urine and stools are dis- 
charged involuntarily. Death finally occurs in this condition, or 
is hastened by an attack of convulsions. In some cases it is most 
lingering. In one instance I expected the death of a young child 
in this disease every day for eight in succession. 

The duration of tubercular meningitis is exceedingly variable 
in different cases. As a general rule it lasts between eleven and 
twenty days, though it may continue a considerably longer time. 
Rilliet and Barthez have never known death to occur before the 
seventh day. 

Diagnosis. — The diseases with which tuberculosis of the me- 
ninges is most likely to be confounded, are simple meningitis, and 
typhoid fever. It might also be confounded, though this is much 
less probable, with the cerebral symptoms which complicate the 
exanthemata and some local diseases, and to which as a group, M. 
Barrier has applied the term pseudo-meningitis. 

The diagnosis between tubercular and simple meningitis will be 
best understood from the following synoptical table extracted from 
the work of M. Valleix, and from a paper by M. Rilliet ( Arch. 
Gen. de Med. t. xii, 1846). 

Simple Acute Meningitis. Tuberculosis of the Meninges. 

No antecedent symptoms. Antecedent symptoms of tubercles. 

Symptoms of the invasion more vio- Symptoms of invasion ordinarily 

lent, more distinct, more character- less violent, occurring slowly, often 

istic, especially in idiopathic cases. insidiously. 

Violent delirium, very suddenly Delirium less violent, often tranquil, 

established ; (phrenitic form of M. appearing later, and arriving less ra- 

Rillict.) pidly at its summum. 



340 TUBERCULAR MENINGITIS. 

In a certain proportion of cases, No convulsions at the commence, 

frightful convulsions at the commence- ment. 
merit ; (convulsive form of M. Rilliet.) 

Very severe headache ; suffusion of These symptoms sometimes absent, 

the face, photophobia, etc.; these especially at the commencement ; they 

symptoms strongly marked. are almost always less strongly marked. 

Vomiting more frequent, and more Vomiting less frequent, and less 

abundant. Constipation moderate, abundant. Constipation very obstinate. 

Pulse often slower than natural at the Pulse more frequent, stronger, less 

commencement ; more irregular. irregular. 

Progress continuous, without per- Progress continuous, but ordinarily 

ceptible remissions. with very perceptible remissions. 

Duration shorter; from one to six Duration much longer, 
days, rarely longer. 

Before quitting the subject of the diagnosis of these two affec- 
tions, it is desirable to state for the information of the reader, that 
some of the highest authorities acknowledge it to be sometimes 
nearly or quite impossible to distinguish between them. This is 
the expressed opinion of MM. Guersent, Rufz, Barrier, and 
Valleix. 

From typhoid fever tubercular meningitis is to be distinguished 
by the antecedent history of the patient, which often reveals the 
existence of a tubercular diathesis in the latter affection ; by the 
symptoms of the invasion, which in meningitis consist of severe 
and persistent headache, frequent vomiting, and constipation, whilst 
in typhoid fever the headache is less severe and less persistent, the 
vomiting much less frequent, and the constipation replaced by 
diarrhoea ; by the different characters of the febrile movement, 
which, in typhoid fever, is more marked, and attended with a fre- 
quent, full, and regular pulse, while in meningitis it is less marked 
and is accompanied after a kw days by slowness and irregularity 
of the pulse ; lastly, in meningitis, the constipation is obstinate, the 
abdomen retracted, and there are various important and charac- 
teristic lesions of motility, sensibility, and the senses ; in typhoid 
fever, there is diarrhoea, the abdomen is distended and meteoric, 
there are characteristic rose-coloured spots, whilst there are no 
considerable lesions either of motility, sensibility, or of the senses. 

It is unnecessary to do more than allude to the possibility of 



PROGNOSIS. 341 

confounding the disease with the exanthemata, or with local diseases 
accompanied by cerebral symptoms, and particularly with pneu- 
monia in very young children. The diagnosis must be made by 
careful consideration of the symptoms peculiar to each, and in the 
case of a local disease, by accurate physical examination of all the 
important organs of the body. 

Prognosis. — M. Barrier, in speaking of the prognosis of this 
affection says : " The gravity of tubercular meningitis is not sur- 
passed by that of any other disease. Thoracic and abdominal 
phthisis, though almost constantly fatal, pursue a slower course, 
and last a longer time. We may even allow as proved, that in a 
small number of cases, they are susceptible of cure, or may remain 
stationary for months or years. Unfortunately it is not so in re- 
gard to tubercular meningitis." Rilliet and Barthez remark : 
" For our part we have not seen a single case of tubercular menin- 
gitis terminate in recovery, and our experience confirms that of 
MM. Rufz, Piet, Gerhard, Green, etc." They add that they have 
not been able to find any authentic cases of cure in the French 
journals. M. Valleix is of opinion that after having acquired the 
conviction that a case is really one of tuberculosis of the meninges, 
we should regard the patient as lost ; " for the exception which I 
have mentioned, (a case belonging to M. Rilliet, then unpublished), 
even did no doubt as to the exactness of the diagnosis remain, 
ought not, standing by itself, to impart to us any real security." 
M. Guersent [Diet, de Med. t. xix, p. 403,) seems to think it pos- 
sible that the disease may sometimes terminate favourably in the 
very early stage, but adds that " such cases are always more or 
less doubtful, and seem to us to belong rather, for the most part, 
to simple meningitis." During the second period, (slowness and 
irregularity of the pulse,) he has scarcely seen one child in a hun- 
dred survive, and even then they perished at a later period of the 
disease, or of phthisis pulmonalis. Of those arrived at the third 
stage, (marked by renewed frequency of the pulse, coma, and lesions 
of motility and sensibility,) he has never seen any recover, even 
momentarily. Dr. Geo. B. Wood, (Pract. of Med. vol. ii, p. 635,) 
states that he has " never seen a well-marked case of tuberculous 
meningitis end favourably." My own experience coincides with 

29* 



342 TUBERCULAR MENINGITIS. 

the mass of evidence given above as to the hopeless fatality of the 
disease. The ten cases that I have seen all perished. I have 
seen but one which gave me the least reason for hope, after I had 
once supposed the child attacked with the disease. This occurred 
in a boy eight years old, who had been suffering for two weeks 
before I saw him with violent frontal headache, frequent vomiting, 
constipation, slight fever, and somnolence. I fully expected that 
this would prove to be an attack of tubercular meningitis. A large 
dose of calomel followed by castor oil, and free leeching to the 
temples, relieved him in two days perfectly, and he has remained 
well ever since, though this was nearly three years ago. With 
one more authority as to the prognosis of the disease, I shall con- 
clude. Dr. Robt. Whytt, {Works of Robert Whytt published by 
his son, quarto, Edinburgh, 1768, p. 745,) says: "I freely own, 
that I have never been so lucky as to cure one patient who had 
those symptoms which with certainty denote this disease; and I 
suspect that those who imagine they have been more successful 
have mistaken another distemper for this." 

Are we then to abandon utterly all hope of deriving good from 
medicine in the disease under consideration ? To this momentous 
question we ought, it seems to me, to respond in the negative. 
What then are the grounds for entertaining hope where, from the 
quotations given above, all that has as yet been done seems to 
have failed so completely? They are first, the evidence of M. 
Guersent that he has seen cases which appeared to be tubercular 
meningitis recover in the first stage. Granted that they were 
cases of simple inflammation. But they were undistinguishable 
from the tubercular disease by one of the most celebrated of mo- 
dern physicians. Surely, therefore, it may happen to men of in- 
ferior skill to meet with the same difficulty, or if I may so speak, 
to make the same mistake. It is said by M. Valleix, that M. 
Rufz, after determining at the autopsy, that a case which he had 
witnessed was one of simple meningitis, asserted that it would have 
been impossible to distinguish it from the tubercular disease during 
life. Again, M. Rilliet has, according to M. Valleix, seen one case 
of recovery from what he believed to be the tubercular affection. 
I know of the occurrence of a case in this city, under the charge 



PROGNOSIS. 343 

of one of my friends, than whom I believe no one can be more 
competent to make a correct diagnosis, in which, after the child 
had presented in regular order all the early symptoms of the dis- 
ease, and had arrived at the last and most hopeless stage, perfect 
recovery, to his utter amazement, gradually took place. This 
child, when my friend last heard of it, three months afterwards, 
was in all respects strong and hearty. No doubt the probabilities 
are that the case was one of simple meningitis, but who could have 
known this at the time ; and should it not deter us from abandon- 
ing all hope, and, as a consequence, all active treatment, when we 
seem to have under our hands a case of this dreadful malady. 

It is important, in tubercular meningitis, to avoid making a po- 
sitive prognosis as to the period at which death will occur, notwith- 
standing that the patient may present every mark of an imme- 
diately fatal termination. I have already adverted sightly to this 
subject. On one occasion I expected the death of a patient with 
this malady for three days in succession, and on another, I visited 
a child for a week, during every day of which it seemed as though 
existence could not endure until the next. It had during this time 
profound coma, subsultus tendinum, and enlarged pupils ; the eye- 
lids were half open, the eyes constantly oscillating, or else rigidly 
distorted, and both corneas dimmed and slightly eroded, from con- 
stant exposure to air and light. Convulsions occurred from time 
to time, the pulse was variable and at times exceedingly frequent, 
and indeed everything threatened a speedy termination. Rilliet 
and Barthez say " often have we inscribed upon our notes death 
imminent, and been astonished the next day to find still alive, chil- 
dren to whom we had allowed scarcely two hours of life." 

The symptoms which most positively indicate the near approach 
of death are : livid colour of the face, sweats occurring about the 
face, glassy expression of the eye, dry and incrusted nostrils, very 
rapid pulse, and still more strongly, the various nervous symptoms 
mentioned, as carphologia, subsultus tendinum, and particularly 
general convulsions. 

Treatment. — The methods of treatment which have been pro- 
posed at different times having all failed, it becomes very difficult 
and embarrassing to determine what ought to be recommended. 



344 TUBERCULAR MENINGITIS. 

As, however, there can be no doubt that simple meningitis has 
sometimes been mistaken for this affection, and as the state of the 
diseased organ after death proves the existence of an inflammatory 
element in the disease, it would seem most reasonable to employ 
the antiphlogistic plan, until more extended observation and greater 
experience shall either discover another and better method, or show 
the entire futility of this. By this method we at the same time do 
what is most proper should the attack chance to prove one of 
simple inflammation, and employ the means most likely to remove 
the inflammation of the meninges which accompanies and is the 
consequence of the tubercular deposit. Moreover, from all that I 
have read and seen, it seems to me that whenever cases have been 
reported as cured or even only ameliorated, it has been under the 
influence of antiphlogistic remedies, including calomel, and more 
or less powerful counter-irritants. 

In the first stage, the treatment ought to begin with bloodlet- 
ting. It is preferable always to employ venesection, unless there 
be some positive contra-indicating circumstance. This is the 
expressed opinion of most writers. Some recommend opening 
the jugular vein as the most direct means of acting upon the 
cerebral circulation, while others propose that the operation be 
performed in some of the veins of the inferior extremities, as 
effecting an useful derivation at the same time that it yields the 
requisite amount of blood. For my own part I have been satisfied 
to bleed at the usual place, unless there was some difficulty in 
finding a vein, in which event I have had recourse to the vessel 
running over the inner malleolus. The quantity of blood to be 
taken must depend on the age, constitution, and previous health 
of the patient. When the child is over two or three years old, 
with the appearances of good health, the quantity may vary be- 
tween four and eight ounces ; in younger children it should rarely 
exceed four. The bleeding may be repeated if the pulse continues 
tense and the flushing of the face fails to subside after the first 
operation, or we may resort to leeches or cups. Rilliet and Bar- 
thez prefer local to general bleeding, and recommend that the 
leeches be applied to the anus or inferior extremities, in order to 
obtain a derivative as well as depletory effect. Where all remedies 



TREATMENT. 345 

are of so little avail as they seem to be in the disease under consi- 
deration, it is difficult to decide on the most proper course, not only 
as to the selection of means, but as to the extent to which they are 
to be employed. It seems to me, however, that the advice given 
by the authors just quoted, to employ bloodletting only at the inva- 
sion of the disease, is the most prudent. They state that " em- 
ployed in the second and particularly in the third stages, their in- 
evitable effect is to increase the nervous symptoms ; the delirium 
becomes more violent, and the coma, if it existed, augments ; we 
have several times observed this." Dr. Gerhard, whose opinions 
on this subject are deserving of great weight, advises that local 
bleeding be directed " so long as the patient can bear it, that is to 
say, until he becomes pale, and the flush is gone, whether the other 
symptoms abate or not" {Clinical Lect. by Graves and Gerhard, 
Phil. 1842, p. 473). 

After bleeding it is proper to employ some kind of counter-irri- 
tation, which may consist of blisters applied to the nape of the 
neck, or behind the ears, to be kept discharging for several days, 
of sinapisms to the extremities, and of mustard pediluvia. To be 
of any probable service these remedies ought to be perseveringly 
and patiently employed for several days, or during the whole of 
the second stage. 

The head ought to be kept cool by means of cold applications, 
consisting of cloths wet with cold water, of affusions with cold 
water, or, as has been proposed by M. Guersent by the use of irri- 
gation as employed in surgery. M. Guersent prefers this mode of 
applying cold to any other, believing it to be the most convenient 
and comfortable to the child, and from its continuous action, the 
most efficacious. To make use of it the hair ought to be shaved 
or closely cut ; the child is to be placed upon a mattrass without a 
pillow, and with the head near the edge of the bed. The head is 
then covered with compresses of soft rag, or better still, patent lint, 
while under it is placed a piece of oiled silk or india-rubber cloth, so 
arranged as to keep the thorax from being wet, and doubled into a 
gutter above to convey the water off into a vessel placed on the 
floor. A bucket or basin filled with fresh, cool water is placed 
near the head of the bed, and from this a syphon made of lint or 
lamp-wick is so arranged as to convey a stream of water upon the 



346 TUBERCULAR MENINGITIS. 

compresses covering the head. If the heat of the whole body falls 
so much as to threaten collapse, after the irrigation has been con- 
tinued for some time, the stream of water should be stopped, and 
compresses merely, wet with water not quite so cool, kept on the 
head. The latter precaution is necessary in order to prevent inju- 
rious reaction from the sudden and total removal of so powerful a 
sedative as irrigation proves to be. 

Some practitioners prefer the use of ice in a bladder. This 
seems to me, however, too severe a remedy to be long continued, 
and I would therefore rather use only cloths wet with iced water, 
or irrigation. Dr. Abercrombie is of opinion that the application 
of cold is by far the most powerful local remedy that we have. 
M. Gendrin recommends cool or cold affusions over the whole 
surface, the temperature to be proportioned to the heat of the skin. 
When there is but little heat of head, only a slight febrile move- 
ment, and the headache is not relieved by cold applications, Guer- 
sent recommends the substitution of warm poultices to the scalp, 
in the place of irrigation or cold applications. 

Purgatives ought to be employed so as to secure a moderately 
free state of the bowels. To use them to such an extent as to 
procure very frequent and watery stools, with the view of obtain- 
ing a strong derivative action upon the intestinal mucous mem- 
brane, can only, it seems to me, be injurious, by increasing the 
febrile reaction and nervous disorder already existing. Dr. Aber- 
crombie, it should be stated, however, regards purging as the most 
efficient treatment that can be employed. He says, " In all forms 
of the disease, active purging appears to be the remedy from which 
we find the most satisfactory results." He recommends the use of 
croton oil. Calomel, on account of its powerful antiphlogistic and 
sedative action, is the best purgative to be given at an early period 
of the disease. From two to eight grains, according to the age of 
the child, may be exhibited in a single dose, to be followed in 
several hours by some other purgative. This may be castor oil, 
jalap, magnesia, rhubarb, extract of senna, or salts. Remedies of 
this class should be repeated from time to time throughout the case, 
according to the condition of the bowels. 

Besides antiphlogistics, counter-irritants and evacuants, which 



TREATMENT. 347 

have just been considered, there are two other remedies which 
have obtained some reputation in the treatment of the disease. 
These are calomel, given as an alterative, and iodine. Calomel is 
highly recommended by most of the English writers on acute hy- 
drocephalus, and is asserted to have effected cures when it has been 
pushed to such an extent as to produce salivation. But little de- 
pendence, however, can be placed on these assertions, as in all pro- 
bability, the reported recoveries occurred in cases of simple menin- 
gitis. The French writers, whose correctness of diagnosis is pro- 
bably more to be depended upon, speak of having used it in very 
large quantities without any success. It was given to many of the 
patients of Rilliet and Barthez, in the quantity of from six to ten, 
increased to twenty grains, in twenty-four hours, in connexion with 
frictions with mercurial ointment, of which two drachms and a 
half were used at first, and the quantity afterwards doubled and 
trebled. They state that salivation did not occur in any of the 
cases, though fetor of the breath and inflammation of the gums 
were of frequent occurrence. It has already been stated that all the 
cases of these gentlemen proved fatal. Calomel may be given, as 
has been remarked, in purgative doses, at the beginning, and for 
the purpose of procuring its specific effects. With the latter view 
the dose may be from a quarter of a grain to a grain, every hour 
or two hours. Mercurial inunction in conjunction with the internal 
administration of the remedy, has been highly recommended by 
several writers as an efficient means of procuring the full effect of 
the drug upon the constitution. About a drachm of the ointment 
is to be rubbed into the insides of the arms and thighs morning 
and evening, and the quantity gradually increased if no effect is 
produced. For my own part, I will merely state that I have never 
known calomel given in large quantities, in order to procure sali- 
vation, of the least benefit in the disease. On the contrary, I can- 
not but think that the violent irritation of the digestive mucous 
membrane which it has determined, whenever I have used it 
largely, and the inflamed, irritated condition of the mouth which it 
caused in one case, must have been a serious aggravation of the 
state of disease under which the constitution was labouring. Mer- 
cury is well known to be an injurious and dangerous remedy in 



348 TUBERCULAR MENINGITIS. 

the tubercular diseases of adults, having for effect to increase 
the dyscrasia of the constitution, which always exists, and thereby 
hasten the progress of the malady. Why it should have a different 
effect in children is difficult to understand. It may be said, to be 
sure, that in the disease we are considering, it is given to overcome 
the inflammatory element of the malady, which, for the time, con- 
stitutes the danger of the case, and also to allow the patient the 
chance of its beneficial operation should the disease happen to be 
one of simple meningitis. But we are of those who deem it against 
morals to risk a wrong that good may perchance arise. I would 
therefore, in a case which I believed after mature and careful con- 
sideration, to be one of tuberculous meningitis, use mercury merely 
for its temporary sedative action, and not in the large quantities 
recommended with a view of obtaining its peculiar action, at least 
not until further evidence of its utility is brought forward. In 
support of the view just expressed, I will quote the following 
opinions of Dr. John Abercrombie, ( Diseases of the Brain and 
Spinal Cord, Philad. ed. 1831, p. 173-6) : " Mercury has been 
strongly recommended in that class of cases which terminates by 
hydrocephalus, but its reputation seems to stand upon very doubtful 
grounds. In many cases, especially during the first or more 
active stage, the indiscriminate employment of mercury must be 

injurious In the preceding observations, I shall perhaps 

be considered as having attached too little importance to mercury 
in the treatment of this class of diseases, particularly in the treat- 
ment of hydrocephalus ; but in doing so, I have stated simply 
what is the result of an extensive observation, and I con- 
fess, the result of my own observations is, that when mercury is 
useful in affections of the brain, it is chiefly as a purgative." 

It has been recommended within a few years, by Sir B. Brodie, 
to employ mercurial inunction as especially applicable in giving 
mercury to children. He advises that a drachm or more of the 
ointment be spread upon one end of a flannel roller, which is to be 
applied, not very tight, around the knee ; repeating the application 
daily. " The motions of the child produce the necessary friction ; 
and the cuticle being thin, the mercury easily enters the system." 

The editors of the journal in which this communication is made 



TREATMENT. 349 

(Braithw. Retrosp. of Med. vol. xiv, 1846, p. 147, from Quart. 
Med. Rev., July, 1846, p. 169) state that they tried this plan in a 
case of acute hydrocephalus, in which some of the most urgent 
and fatal symptoms were present ; " such as very dilated pupils, 
constant convulsions, hemiplegia, and more or less stertorous 
breathing ; in short, so violent were the symptoms, that we con- 
sidered the case perfectly hopeless ; but on reflecting on Sir Ben- 
jamin's method, we ordered the strong mercurial ointment to be 
smeared on each leg, every 12 hours, and covered with a stocking 
made to tie tightly above the knees. The symptoms soon began 
to abate, and by following this up with small doses of iodide of 
potass, frequently repeated (gr. i, every three or four hours), the 
head symptoms vanished. 

In a second case, the same set of symptoms were approaching, 
but were stopped by the same mode of treatment." 

It has been proposed to employ iodine because of its good effects 
in different scrofulous and tuberculous diseases. I am not aware 
of its having been tried in any considerable number of cases. M. 
Rilliet, however, (Loc. cit. t. hi, 1847, p. 308,) states that it has 
entirely failed in his hands in the tubercular form of the disease ; 
the only influence which it seemed to exert was to cause the im- 
mediate suspension of the coma. This was its effect also in a 
case in which I employed it, that of a girl seven years old, to 
whom I gave two drops of Lugol's solution three times a day, from 
the thirteenth to the twentieth day, when she died. The day be- 
fore her death she seemed to improve somewhat, and I was in hopes 
that it had been of some service. The amelioration did not con- 
tinue, however, and I am now disposed to believe that the change 
was one of those which often take place naturally in the disease. 
In another case of a boy five years old, I gave it in the form of 
the iodide of potassium, a grain four times a day, from the tenth to 
the eighteenth day, when he died. I could not perceive that it 
exerted the least influence on the progress of the disease. It is, 
nevertheless, a remedy which ought to be tried. I would recom- 
mend the use of iodide of potassium in doses of a grain every three 
or four hours for children two years of age. It ought to be begun 
with as soon as the acute symptoms have been sufficiently reduced 

30 



350 TUBERCULAR MENINGITIS. 

by bloodletting and purging, and continued in connexion with 
counter-irritants and cold to the head. 

When the convulsive symptoms are violent and distressing, they 
may often be moderated by the use of a warm bath, which must 
be carefully given, and by the administration of some of the anti- 
spasmodics. I prefer for this purpose the fluid extract of valerian, 
of which from three to five drops may be exhibited every two or 
three hours to young children, and a larger dose to those who are 
older. 

As a general rule, narcotics of all kinds are to be avoided, from 
their effect of increasing the constipation, and exciting more or 
less the cerebral circulation. When, however, neither antiphlo- 
gistics, evacuants, nor cold or warm applications relieve the suffer- 
ings of the child, it would be proper to employ small laudanum 
poultices or opium plasters upon the forehead or temples, or we 
may use morphia by the endermic method. 

The treatment described in the preceding pages, is that which 
is proper for cases of the disease occurring in subjects previ- 
ously in good health, or evincing but few signs of the tubercular 
cachexia. When, on the contrary, it occurs in children with ex- 
tensive tubercular affections of other organs, by which they are 
already weakened and exhausted, the treatment must of course be 
modified to meet the circumstances of the case. It ought to con- 
sist chiefly of local bleedings used with great moderation, of purg- 
ing when constipation is present, of counter-irritants, of cold ap- 
plications, and of an early use of iodine or of the iodide of iron. 
We should recollect that experience has long since shown the 
weakness of our art in such cases, and for that reason avoid such 
a degree of interference as might possibly abridge the little span 
of life allowed the patient by this relentless malady. 

Prophylactic treatment. — It must be evident that the prophy- 
lactic treatment is of especial importance in a disease so little ame- 
nable to curative means as the one under consideration. When 
therefore there is reason to suspect a tendency to tubercular me- 
ningitis in a child, either from the fact that other children in the 
family have perished with it, or from a bad state of the general 
health and frequent complaints of headache, it becomes proper and 



TREATMENT. 351 

necessary to regulate both the moral and physical education with 
a view to its prevention. For this end the hygienic management 
of the child ought to be such as is best calculated to prevent 
the formation or development of tubercles in the constitution. 
During infancy, such a child should be nursed, if this be pos- 
sible, by a strong, hearty woman, with an abundant flow of milk. 
If the mother is not herself possessed of these qualities, if there be 
the least doubt upon the point, she ought without hesitation to give 
up the pleasure of nursing the child herself, and procure for it a 
wet-nurse of the kind described. This alone will, in all proba- 
bility, often make the difference between a vigorous and fragile 
constitution. When the time for weaning arrives, that change 
ought to be made with the greatest care and circumspection. 
During and for some time after weaning, the diet must consist 
principally of milk preparations and bread, and of small quantities 
of light broths, or of meat very finely cut up. As the child grows 
older, the meals ought be arranged at regular hours, and should 
consist of four in the day. The principal food must be bread and 
milk well chosen, well-cooked meats, and rice and potatoes as 
almost the only vegetables. After the first dentition is completed, 
a moderate use of ripe and wholesome fruits may be allowed, but 
always with care, in order to avoid injury to the digestive organs, 
and also so as not to mar the appetite for more wholesome and 
nutritious food. Coffee and tea ought to be forbidden at all times. 
It is best that the child should not even taste them, so that it may 
not be tormented with the desire of having what is improper. 

After diet the most important points in the treatment are air and 
clothing. The child should inhabit if possible a large, dry, well- 
ventilated room, which ought to be kept as cool as possible in sum- 
mer, and moderately warm in winter. Not a day should be al- 
lowed to pass, unless the weather is totally unfit, without the child's 
being sent for several hours into the open air, and I believe, that 
it is much better for it to walk than ride, unless the weather be 
very hot. The clothing ought to be suitable to the season, cool in 
summer, and warm in winter. In our country there is a great 
inclination to harden children by dressing them very slightly in 
cold weather ; so that they frequently suffer from catarrh, pneu- 



352 SIMPLE MENINGITIS. 

monia, and spasmodic croup, brought on by improper exposure. 
This cannot but be wrong in a child who shows the least evidence 
of a tendency to tubercular affections. 

For my own part I am fully convinced from what experience I 
have had of the diseases of children, that by far the most certain 
and effectual means of preventing the development of a tubercular, 
or indeed any other cachexia in a child, is to have it brought up 
in the open country, or in some healthy village, until the epoch of 
puberty has passed by safely. A very good plan for parents 
whose occupations compel them to live in cities or large towns, is 
to have their residence a few miles in the country and to come to 
town every day. Children brought up in this way have a far 
better chance of obtaining strong and vigorous constitutions than 
those reared entirely in the close and confined dwellings and streets 
of crowded cities. 

As to the particular means likely to be of service in preventing 
a direction of tubercular cachexia towards the brain, so as to pro- 
duce tuberculosis of that organ, we have only to propose the course 
recommended by different writers, to keep the head cool, by not 
allowing it to be very warmly covered, and by keeping the hair 
short ; to keep the extremities warm ; to avoid stimulating the in- 
tellectual faculties to any considerable extent by education, until 
after eight or ten years of age ; and to use every means to pre- 
serve the general health in a sound and pure condition. Some recom- 
mend the long-continued employment of a powerful derivative 
from the brain, as a small blister on the arm, or a seton in the 
neck. It seems to me, however, that such remedies ought not to 
be used unless there are positive symptoms of a tendency to cere- 
bral disorder. The caution not to interfere much with eruptions 
which nature may have thrown out upon the scalp is, I believe, 
wise and prudent. 



ARTICLE II. 

SIMPLE MENINGITIS. 

Definition ; synonymies ; frequency. — By this term is under- 
stood inflammation of the membranes of the brain, independent 



FREQUENCY CAUSES. 353 

of tuberculosis of those tissues, or of other organs of the eco- 
nomy. 

The disease was for a long time confounded with tubercular 
meningitis under the titles of water on the brain, dropsy of the 
brain, and acute hydrocephalus. It has also been called arach- 
nitis ; and more rarely phrenitis. 

Its frequency is much less than that of tubercular meningitis. 
It appears that Rilliet and Barthez, during their researches, met 
with only five cases of this disease, while they report thirty-three 
of tubercular meningitis. Bouchut states that he has met with 
two cases of simple meningitis to six of the tubercular disease, 
whilst Barrier reports only four of the former in nearly thirty 
autopsies of meningitis. He states, however, that he has met with 
three cases of recovery, all of which he believes to have been in- 
stances of the simple form. Fabre and Constant met with nine 
cases of simple to twenty-seven of tubercular meningitis in a 
period of two years, at the Children's Hospital of Paris. (Biblio- 
tkeque du Med. Prat. t. vi, p. 166.) 

Causes. — The causes of simple meningitis are not very clearly 
ascertained. It would appear, however, that the disease is more 
common in infants than older children. M. Rilliet, who has 
recently published a very valuable paper on this affection ( Arch. 
Gen. de Med. t. xii, 1846), divides it into two forms, the convul- 
sive and phrenitic, the former of which he believes to be most 
common under two, and the latter between five and fifteen years 
of age. This author is disposed to think, from the fact that the 
disease is most frequent in the first and ninth years of life, that 
the process of dentition has something to do in its production. It 
appears also to be more frequent in boys than girls, and in robust 
than in weak constitutions. Guersent has known it to follow long- 
continued exposure to the sun in several instances, particularly in 
young infants ; Rilliet and Barthez report a case of the same 
kind, and Rilliet (Loc. cit.) another ; other causes cited by 
authors are injuries upon the head, such as blows, falls, and 
wounds. One other cause I will mention, which ought to be 
known to every practitioner. That is the attempt to cure chronic 
eruptions of the head, especially by too active a treatment. A 

30* 



354 SIMPLE MENINGITIS. 

case of this kind is given by Rilliet and Barthez ; another by 
Rilliet, and I am acquainted with one myself. 

The disease sometimes occurs in an epidemic form. 

Anatomical lesions. — The dura mater is generally much in- 
jected, and its sinuses, together with the large cerebral veins, con- 
tain coagulated or semi-coagulated blood, sometimes in large quan- 
tities. On opening the dura mater, the whole, or nearly the whole 
of the convex surface of both hemispheres, or in some cases only 
one, are found to be covered with a yellowish or greenish-yellow 
layer, which consists of fluid or concrete pus, or of false mem- 
branes. These deposits exist also on the internal surfaces of the 
hemispheres, on the upper surfaces of the cerebellum, and often 
also at the base of the brain, though, in some cases the latter pre- 
sents none whatever. These inflammatory products are always 
seated in the pia mater, and sometimes in the cavity of the arach- 
noid membrane, but in much smaller quantity than in the tissue 
beneath that membrane. 

The arachnoid membrane which covers the brain seldom par- 
ticipates in the inflammation, but remains smooth and transparent. 
Its cavity, however, often contains inflammatory products, which, 
when death occurs early in the attack, consist of a small quantity 
of pure pus, or of larger quantities of a turbid, yellowish serosity, 
consisting of serum and pus mixed together. When death has 
occurred later in the disease, — after five, six, or seven days, — the 
pus is found converted, by the absorption of its fluid particles, into 
a solid substance, or else true false membranes are found. The 
pia mater is observed to contain fluid or semi-fluid pus, when death 
occurs before the fourth or fifth day, while at a later period the 
pus has become hardened, so as to form a layer, which sometimes 
dips into the anfractuosities, and gives to the membrane under 
consideration a swelled and thickened appearance. These appear- 
ances are more marked on the superior and lateral, than on the 
inferior surface of the brain. Where the deposits exist the mem- 
brane presents a vivid injection, which is more marked in propor- 
tion as death has taken place earlier in the disease. The pia 
mater is generally easily detached from the cerebral substance, 
particularly when the fatal termination has occurred early. The 



ANATOMICAL LESIONS. 355 

substance of the brain is firm, and but slightly coloured, in rapid 
cases. When the course of the 'disease has been slower the cine- 
ritious portion is generally of a bright rose colour, and the medul- 
lary substance abundantly dotted with red. In the latter class of 
cases the surface of the convolutions is sometimes softened, and 
the pia mater adherent. In very young children, the whole brain 
is sometimes soft. 

The ventricles do not, as a general rule, contain transparent 
serum, except at a very early age, when serous effusion takes 
place with great facility. They often, however, contain one or 
two teaspoonfuls, and rarely more than one or two tablespoonfuls, 
of pus or purulent serum. The serous membrane of the ventricles 
and the plexus choroides exhibit signs of inflammation in some in- 
stances. They are of a bright red colour, uneven, rough, and 
very much softened, in children who die early ; and pale, opaque, 
slightly thickened and rough, in those who die at a later period. 

The central parts of the brain often retain their firmness, but are 
sometimes softer than natural, or even diffluent. This softening 
is particularly apt to exist in very young children, in connexion 
with large effusion into the ventricles ; though it also occurs in 
those who are older, and in whom there is only slight effusion, of 
pus or purulent serum. In the former case it is probably due to 
the macerating effect of the effusion, while in the latter it is more 
likely to be owing to inflammation. 

The spinal marrow was examined in one case by M. Legendre, 
and its membranes found to present the same inflammatory ap- 
pearances which existed in those of the brain. 

The other organs are healthy except in secondary cases. Tu- 
bercles, which so constantly exist in various other organs in tuber- 
culosis of the meninges, are never found, according to M. Rilliet, 
in this form of meningitis. This author believes himself entitled 
from his researches to formulate the following law of pathological 
anatomy : " That general meningitis and meningitis of the convexity 
of the brain occur only in non-tuberculous children, whilst meningitis 
of the base of the brain, without inflammation of the lining mem- 
brane of the ventricles, belongs exclusively to tuberculous chil- 
dren." (Loc. cit. t. iii, 1846, p. 408.^ 

Symptoms. — The following account of the symptoms of the 



356 SIMPLE MENINGITIS. 

disease is taken chiefly from the paper of M. Rilliet. That author 
describes two forms of the affection, the convulsive and phrenitic ; 
the former of which is characterized by a predominance of con- 
vulsive phenomena, and the latter by that of disorders of the intel- 
ligence. 

The disease may also be idiopathic or secondary, simple or com- 
plicated, sporadic or epidemic. 

The convulsive form generally occurs in children under two 
years of age. The disease usually begins suddenly or after a 
restless night, with a violent and prolonged attack of convul- 
sions, oftener general than partial, and is accompanied by vio- 
lent fever, and sometimes by considerable quickness of respira- 
tion. The existence of headache cannot be ascertained at this 
early age. Vomiting is often absent, and the boivels generally 
continue regular in this form, though they are sometimes consti- 
pated. After a while the convulsions cease, and the child remains 
for a time in a state of quiet, somnolence, or coma, when they re- 
turn with renewed violence. The returns of the convulsions gene- 
rally take place at intervals of one or two hours or longer. In the 
intervals between the crises the child is restless or drowsy, or in a 
state of partial stupor, attended with tremulous movements of the 
extremities ; there is strabismus, contraction of the pupils, trismus, 
and sometimes hemiplegia. The skin retains its warmth, the 
pulse is accelerated, irregular, and unequal ; the face is pale ; 
the stools are spontaneous or easily procured by remedies. It is 
unusual to see the child regain its consciousness so as to recognise 
objects, in the intervals between the convulsions, or after the ap- 
pearance of coma and other cerebral symptoms. Death occurs 
during coma or in a violent attack of convulsions. This form 
seldom lasts more than four days. 

M. Rilliet states that this form sometimes begins in a different 
manner. The convulsions, though they still predominate, do not 
occur until later in the disease, and the whole course of the affec- 
tion is slower. Such cases begin with a violent febrile movement, 
lasting several days, and accompanied by acceleration or unevenness 
of the respiration, or by almost constant drowsiness, preceded or 
followed by agitation, screaming, staring expression of the eyes, 
and dilatation of the pupils ; vomiting and constipation are some- 



SYMPTOMS. 357 

times present, at others absent. After a time, however, con- 
vulsions make their appearance, and the case follows the course 
already described. The duration of this form may be the same 
as that of the first, or it may last about two weeks. 

The phrenitic form, of simple meningitis generally begins sud- 
denly with fever, which is sometimes preceded by a chill ; the 
skin is warm and dry, and the pulse, in idiopathic cases, full and 
accelerated. In secondary cases the pulse has been found slow 
and irregular ; in all it becomes irregular, small, and very rapid, 
the day before death. Simultaneously with the fever there is 
frontal headache, which is often so violent as to draw cries from 
the child, and, according to M. Rilliet, is more severe than either 
in tubercular meningitis or typhoid fever. It is also more constant, 
and lasts generally one, two, or three days, until the appearance 
of restlessness, delirium, or coma. At the same time there is 
great sensibility to light and noise, and abundant vomiting of 
bilious matter. The latter symptom is one of the earliest; it 
generally ceases after a few days, but sometimes continues to the 
very end. Constipation exists in some cases, but is much less 
constant and more easily overcome than in the tubercular disease. 
The appetite is lost, and the thirst very acute. The abdomen is 
flattened and retracted, especially towards the termination, while 
in secondary cases of this form, and in very young children, it re- 
tains its usual shape. 

About the end of the first day, generally, or in rare instances, 
after two or three days, appear various disorders of the intelli- 
gence. The first symptom of this kind is observable in the ex- 
pression of the face, which becomes a little wild or wandering, and 
sometimes grimacing. Soon afterwards occur restlessness, which 
is sometimes extreme, and, in succession, delirium, somnolence, 
and later in the attack, coma. The restlessness and somnolence 
often alternate early in the case, though the former generally pre- 
dominates and soon passes into delirium, which is usually violent. 
When in this condition the child seldom recognises any one, and 
either refuses to answer questions, or answers incoherently. In 
connexion with the disorders of intelligence there exist also trismus, 
grinding of the teeth, subsultus tendinum, partial convulsive move- 



358 SIMPLE MENINGITIS. 

merits, stiffening of the extremities or trunk, retraction of the head, 
strabismus, contraction first and then dilatation of the pupils, and 
in some cases violent convulsions, followed by deep coma. Death 
sometimes occurs at this period. In other instances the disease con- 
tinues longer, and other symptoms declare themselves. Vomiting 
generally ceases ; constipation increases ; the abdomen is retract- 
ed ; headache is no longer complained of; the fever continues, but 
the pulse becomes irregular ; the respiration is uneven and irre- 
gular, being sometimes more and at others less frequent than na- 
tural ; the face is distorted and extremely pale, or there may be a 
purple flush on the cheeks ; the restlessness is excessive, and ac- 
companied by subsultus, carphologia or partial convulsive move- 
ments ; the delirium, at first so violent as to make it necessary 
sometimes to hold the child in bed, subsides into a state of coma 
and collapse, in which general sensibility is obtunded, and special 
sensibility extinguished ; the respiration becomes stertorous, and at 
length asphyxia, coma, or a severe attack of convulsions terminate 
the scene. 

The course of the disease is generally continuous. In very rare 
cases, however, occasional remissions occur, so that the child 
recovers its intelligence for a short time, and recognises persons 
around. The duration has varied between a day and a half and 
nine days. 

Diagnosis. — The convulsive form may be confounded with 
essential or symptomatic, and with the sympathetic convulsions of 
children. The mistake may generally be avoided by attention to 
the following points. In essential convulsions, the attacks are 
usually less violent, seldom last more than a few moments, occur 
from some evident cause, and do not recur often. When they have 
ceased, the child generally soon regains its consciousness and 
health, or exhibits slight drowsiness or derangement of movement 
for a short time only. In such cases the respiration is not per- 
manently accelerated, as in convulsive meningitis ; the pulse, if it 
had been increased in frequency, soon falls to the natural standard, 
and special sensibility remains undisturbed. 

It is to be distinguished from sympathetic convulsions by the 
characters just described, aided by a reference to the disease which 



DIAGNOSIS. 359 

may have caused the attack of eclampsia, and which may be one 
of the eruptive fevers, enteritis, indigestion, pneumonia, or any 
other acute affection. In some instances, however, the distinction 
cannot be made except by attention to the progress of the attack. 

The phrenitic form may be confounded with tubercular menin- 
gitis, with congestion of the brain, or with the early stage of the 
eruptive fevers. The distinction between it and tubercular menin- 
gitis has already been considered under the head of the latter 
disease. 

M. Rilliet is of opinion that it is sometimes impossible, in the 
present state of knowledge upon these points, to distinguish with 
certainty between simple meningitis and cerebral congestion or 
hemorrhage, and encephalitis. In regard to congestion of the 
brain, he proposes the very important question, " Whether we 
ought to class as meningitis the dangerous cerebral symptoms re- 
sembling exactly those which mark the commencement of menin- 
geal inflammation, and terminating rapidly by death or recovery ?" 
He states that examination after death in these cases reveals neither 
pus nor false membranes in the arachnoid or pia mater, but simple 
congestion of the brain and its membranes. He deems the solution 
of the question to be difficult, but is himself of opinion that they 
ought not to be classed together. He gives the following table, 
which he thinks may assist in making the diagnosis. 

Congestion of the Brain. — Mode of Meningitis. 

Invasion. 

There occurs instantaneously pro- In the phrenitic form the first symp. 
found stupor, absolute immobility and torn is generally headache, which is 
insensibility, with dilatation of the not noted in any of the cases of M. 
pupils, or else acute delirium, with Bland (of congestion). The alterations 
difficulty of breathing, acceleration of intelligence and movements occur 
and smallness of the pulse, or in yet early, but not before the beginning of 
another class of cases tremors or slight the first or second day ; whilst in con- 
convulsive movements of one side of gestion, the appearance of delirium 
the body. Stuttering, loss of speech, or coma, of subsultus tendinum, or 
stertorous respiration or pains in the partial paralysis, is instantaneous, 
arms and corresponding side of the frightful, truly apoplectic, and, so far 
face exist; the fingers do not retain as we can ascertain, not accompa- 
objects which the child attempts to nied by vomiting, — a symptom rare- 
grasp, ly absent in meningitis. 



360 SIMPLE MENINGITIS. 

From the invasion of variola, it is to be distinguished by atten- 
tion to the contagious and epidemic nature of that malady, by the 
absence of vaccination or of a prior attack of the disease, by the 
absence of pains in the loins, and by a consideration of the period 
at which the delirium makes its appearance, which, in variola, 
rarely occurs before the third day. To make the diagnosis between 
meningitis and malignant scarlatina, we must attend chiefly to the 
epidemic and contagious character, to the thick coating upon the 
tongue, redness of the throat, elevated temperature, and strong 
nasal respiration, which exist in the latter. 

Prognosis. — The prognosis of simple meningitis is very grave. 
M. Valleix is disposed to think that most of the recoveries re- 
ported by M. Guersent were cases of sanguine congestion or effu- 
sion. M. Rilliet (Loc. cit.), who has studied the subject more 
carefully than any other observer, cites several instances of re- 
covery, but states that death is much the most frequent termination. 
The diagnosis of the disease from other cerebral affections, is so 
difficult and uncertain, at present, however, as to render it impos- 
sible to determine with any certainty, its degree of curability. 

Treatment. — It must be evident it seems to me, that but little de- 
pendence can or ought to be placed on any but the most powerful 
antiphlogistic treatment. Bloodletting therefore, mercury, cold 
applications to the head, purgatives, counter-irritants, and the 
most rigid diet ought to be employed from as early a period as pos- 
sible, and in the most energetic manner. 

Venesection ought always to be preferred to local bleeding, even 
in the youngest children, unless it is impossible to find a vein, or 
unless this is evidently too small to bleed well. If we cannot 
succeed in performing the operation at the bend of the arm, we 
may resort to the vein running over the inner ankle, or to the ex- 
ternal jugular. When venesection cannot, from any reason, be 
employed, blood should be freely drawn by means of leeches or 
cups. It is customary to apply the leeches to the temples or be- 
hind the ears. I may remark that MM. Rilliet and Barthez object 
to the application of leeches to the head, and propose that they 
should be placed rather about the anus, or on the inferior ex- 
tremities. The quantity of blood to be drawn must depend upon 



TREATMENT. 361 

the age and constitution of the child, and violence of the attack, 
in some measure. It should always, however, be large, as 
much, or more, I think, than what is necessary in any of the acute 
affections of childhood. In a child two years old, of good consti- 
tution, from four to six ounces would not be too much at first, and 
should the symptoms not be moderated in six or eight hours, as 
much more may be taken. Should these detractions of blood fail 
to produce any good effect on the dangerous symptoms, I would, 
unless there were evident and unmistakable signs of exhaustion, 
take still more, either locally or generally. I am disposed to be- 
lieve that in such a disease as this, bleeding is by far the most 
powerful remedy, that it is perhaps the only one which offers us 
any real chance of success, at least in rapid cases, in which exten- 
sive layers of fluid or partially concrete pus and false membranes 
are found on the surface of the brain, in the pia mater, or in the 
sub-arachnoid tissue, in two days and a half, in three, or in four 
days after the commencement of the disease. I once took four 
ounces of blood from a child five weeks old, who was labouring 
under convulsions and insensibility, occurring in the course of 
lobular pneumonia, and the child recovered. In another of 
the same age, with convulsions from congestion of the brain, or 
possibly from the very disease we are now considering, I removed 
four ounces in twelve hours by venesection and leeching; in 
another of seven months, with repeated convulsions, lasting with 
slight intervals for ten hours, and followed by nearly complete 
paralysis of the left arm, I took seven ounces in that time ; 
both recovered and were not permanently injured by the loss of 
blood. I have taken between fourteen and fifteen ounces of blood 
by venesection from a child two years old, attacked with pseudo- 
membranous laryngitis, in two days, and fourteen from another 
four years old in the same time, for the same disease, and have 
seen them both recover without any injury to their constitutions. 
I mention these amounts in order to show that children labouring 
under acute and dangerous inflammations of important organs, 
bear large detractions of blood without injury, and because I know 
that there is a strong feeling amongst many members of the pro- 

31 



362 SIMPLE MENINGITIS. 

fessfon in this city, against copious bleedings in childhood under 
any circumstances. 

While the bleeding is being performed we should direct the 
preparation of means for the application of cold to the head, which 
constitutes, according to all writers, a most efficient remedy in 
inflammations of the brain and its membranes. These may con- 
sist of a bladder containing water and pounded ice, which is per- 
haps the most convenient and powerful, of cloths wrung out in 
iced or very cold water, to be constantly renewed, of cold affu- 
sions upon the head, or, lastly, of irrigation as recommended by 
M. Guersent, and described in the article on tubercular meningitis. 
Purgatives ought to be employed so as to empty the bowels 
thoroughly, and produce a decided revulsion upon the intestinal 
mucous membrane, but not in such quantity as to occasion in- 
flammation of that tissue, which would be very apt to prove the 
case, were the drastic substances and large doses recommended 
by some writers, used. The remedy usually given and most 
highly, recommended is calomel, which is chosen for its sedative 
and alterative properties. About four grains may be exhibited 
alone, and followed in one, two, or three hours by castor oil, jalap, 
or infusion of senna and manna, sweetened with syrup of rhubarb. 
These doses ought to be given until the bowels are freely moved. 
It is always useful to employ a strong purgative enema immediately 
after the bleeding, without waiting for the operation of the internal 
remedies. After the purgative doses have been given, it is impor- 
tant to continue the mercury in smaller doses, with the view of ob- 
taining its specific influence upon the inflammation. These doses 
may consist of from a quarter of a grain to a grain every hour or 
two hours. Some writers also recommend very highly the use of 
mercurial inunction. 

Counter-irritants are useful as adjuvants to the more powerful 
remedies already indicated. During the first day or two they 
should consist chiefly of sinapisms and mustard poultices applied 
from time to time to the trunk and extremities. Authorities differ 
somewhat as to the effects of blisters, and the time at which they 
ought to be applied. M. Valleix (Loc. cit. t. ix, p. 187,) op- 
poses their employment in this affection as often injurious and 



TREATMENT. 363 

still more frequently useless. I believe that the advice given by 
Dr. Abercrombie as to their employment is probably the most 
prudent. This is not to apply them in the early stage, but to 
wait until the active symptoms of the disease have been subdued. 
They may be applied to the head itself, to the nucha, or to the ex- 
tremities. I believe that I have seen them most useful when 
applied to the neck and insides of the calves of the legs. Never- 
theless, there is high authority in favour of their good effects when 
applied upon the head itself. 

M. Rilliet [L,oc. cit.) recommends a vigorous revulsion upon the 
scalp when the disease has followed the suppression of an eruption. 
He proposes with this view the employment of pustulation by 
croton oil, and relates a case of recovery which followed this treat- 
ment under a most unfavourable train of symptoms. To make use 
of it the head must be first shaved; from fifteen to twenty drops 
of the oil are then to be rubbed over the scalp with a glove, four 
or six times a day. Before making the friction, the eyes of the 
patient must be covered with a band to prevent the introduction 
of any of the oil into them, as this would be apt to occasion 
severe ophthalmia. In the case reported by him a considerable 
number of pustules were produced in twenty-four hours, and in a 
few more the eruption was general, so that the head was covered 
with a kind of cap of a fine yellow colour. 



ARTICLE III. 

ACUTE HYDROCEPHALUS. 

Under the term hydrocephalus were formerly included all the 
cases of disease of the brain attended with effusion of serum into 
the ventricles, cavity of the arachnoid or pia mater, or with infiltra- 
tion of the cerebral substance. Recent observations have shown, 
however, as has already been staled in the two previous articles, 
that in the immense majority of cases the serous effusion within 
the cranium depends upon tuberculization of the membranes of the 
brain ; and that of the remaining cases the greater part are the 



364 ACUTE HYDROCEPHALUS. 

result of simple meningitis, or of some other disease of the brain. 
In some few instances, however, effusion undoubtedly takes place 
independently of inflammatory action, and it is to these that the 
title of acute hydrocephalus is now generally applied. It ought to 
be observed, however, that the disease is almost always secondary, 
and that some writers, and amongst them MM. Guersent and 
Blache, Valleix, and Rilliet and Barthez, without denying the pos- 
sibility of the occurrence of idiopathic cases, are evidently of 
opinion that they are extremely rare, and even that their existence 
may be doubted. 

Definition ; synonymes ; frequency. — By acute hydrocephalus 
is now generally understood, at least by the French writers, a 
disease in which a rapid but non-inflammatory effusion of serum 
takes place into the ventricles of the brain, and less frequently 
within the cavity of the arachnoid membrane, or through the sub- 
stance of the brain. 

It has already been stated that under the title of acute hydroce- 
phalus were formerly, and are yet by some persons, confounded, 
tubercular and simple meningitis, and indeed all acute lesions 
of the brain attended with serous effusion. 

It is an affection rarely met with in comparison either with 
tubercular or simple meningitis. It is denied by several high 
authorities to exist at all as an idiopathic disease, while all acknow- 
ledge it to be infrequent even in the secondary -"form. 

Causes. — As even the existence of idiopathic acute hydrocephalus 
is doubted by many, and denied by not a few observers, its causes 
are of course but little understood. The cases of the disease met 
with, therefore, are secondary. These may occur in the course of 
any disease liable to be complicated with anasarca, and particu- 
larly scarlet fever, measles, nephritis, gangrene, and entero-colitis. 
It is said to occur generally under six years of age, and equally in 
both sexes. 

Anatomical lesions. — Rilliet and Barthez state that they have 
rarely found more than from two to four ounces of serum in the 
ventricles, which are more or less dilated, and about the same 
quantity in the cavity of the arachnoid. The internal and exter- 
nal cerebral membranes, generally pale or of their natural colour. 



SYMPTOMS — DIAGNOSIS. 365 

sometimes present a bright injection, thus showing the transition 
from simple dropsy to that which is the result of inflammation. 
The same authors describe the cerebral substance as healthy and 
natural, or as presenting more or less considerable punctuation or 
congestion. In some instances it participates in the dropsy, and 
the parts adjoining the effusion are softened and of a creamy con- 
sistence. This is particularly observable in the walls of the ven- 
tricles when the serum has been effused into those cavities. 

Symptoms. — The symptoms of acute hydrocephalus, like the 
rest of the history of the disease, are very imperfectly understood. 
Rilliet and Barthez, with Guersent and Blache, are of opinion that 
it is difficult and even impossible to establish any characters which 
indicate the presence of acute hydrocephalus. The only symp- 
toms they have been able to refer to it are excessive agitation, 
cries or constant moaning, replaced a short time before death by 
extreme prostration with somnolence, loss of consciousness and 
coma, or even general insensibility, dilatation of the pupils, and 
fixity of the look. 

M. Barrier states that the disease appears under two different 
forms. In the first, the effusion taking place gradually, the symp- 
toms are very analogous to those of the invasion of meningitis, and 
are characterized by phenomena of excitation, such as headache, 
delirium, restlessness, screaming, and convulsive movements. This 
period lasts from a few hours to several days, but very rarely 
so long as the first and second stages of acute meningitis united. 
In the second period of the first form of hydrocephalus now under 
consideration, the preceding symptoms give place to abolition of 
the intelligence and senses, to coma, amaurosis, deafness, insen- 
sibility of the skin, and cessation of all voluntary movements. The 
latter symptom, however, is not constant ; for it often happens that 
violent convulsions occur in the midst of the state of collapse. 

In the second form of hydrocephalus, the first period above de- 
scribed is wanting, and the phenomena of the second period appear 
from the first. This form might with some propriety be called 
serous apoplexy. It is particularly apt to occur in the course of 
the anasarca of scarlet fever. 

The diagnosis of acute hydrocephalus is, as might be supposed 

31* 



366 ACUTE HYDROCEPHALUS. 

from the uncertainty of the symptoms, enveloped in much obscurity. 
I will merely quote the statement by M. Valleix, that if, in the 
course of a dangerous disease, and particularly in the anasarca 
which follows scarlet fever, severe cerebral symptoms without 
paralysis are observed to occur, we may suspect the existence of 
acute hydrocephalus ; the presumption would be still stronger and 
amount almost to certainty were a more or less rapid loss of con- 
sciousness observed to follow the disappearance of a serous effusion 
situated in some part of the body more or less distant from the 
head. 

The prognosis is exceedingly unfavourable, as the disease rarely 
occurs except in the course of, or at the termination of other 
affections which are themselves very dangerous to life. 

Treatment. — The treatment of acute hydrocephalus is rendered 
very uncertain in consequence of the obscurity of the diagnosis. 
Bloodletting, however, has been employed in several cases, and 
apparently with good effects in some which occurred in the course 
of diseases of a manifestly dropsical character. Such was the 
case reported by Dr. M. Hall (.Dis. and Derange. Nerv. Syst. p. 
152,) which occurred in a boy twelve years old on the sixteenth 
day after the invasion of scarlet fever, and came on simultaneously 
with oedema of the face, by a sudden attack of collapse, followed 
by convulsions and coma. Dr. Hall bled the child to. the amount 
of twenty ounces from the jugular vein, when the convulsions 
ceased, but the coma did not disappear. He then took seven 
ounces more from the arm, and in less than an hour the child 
knew his parents. The case terminated favourably. A case is 
reported by M. Barrier (Loc. cit. t. ii, p. 359,) from a memoir on 
acute hydrocephalus by M. Piet, of a girl nine years old, who, on 
the fifteenth day of a very mild attack of scarlet fever, took cold 
in the evening from exposure at an open window, and was attacked 
the next day with tonsillitis, oedema of the face, and then with 
amaurosis, complete immobility of the pupils, violent convulsions 
of the right side, palpitations, and stupor. She w T as treated by 
leeches to the head, tartar emetic, powdered digitalis, and diuretic 
infusions. After five days the oedema and nervous system began 
to moderate, and in a short time she was restored to health. 



TREATMENT. 367 

M. Barrier relates another case published by M. Lecointe, of a 
boy thirteen years old, who, about two weeks after an attack of 
some eruptive disease, which was almost certainly scarlet fever, 
was seized with oedema of the feet, legs, scrotum, and abdomen, 
and with headache. After a short time he was attacked with 
violent epileptiform convulsions, intense headache, and soon after 
with loss of sight and hearing, and stupor. The convulsions were 
frequent, and while they lasted the face became purple, and the 
mouth filled with bloody spume; the contortions were terrible. 
On the first day he was freely leeched along the jugular veins, a 
camphorated blister was applied upon each thigh, and an emollient 
cataplasm upon the abdomen. He took internally a mucilaginous 
drink containing nitre, and ten drops of sulphuric ether in water 
every hour. On the second day the condition remained the same ; 
pupil excessively dilated, pulse hard and accelerated : venesection 
to about sixteen ounces. An hour later, as the convulsions re- 
turned, about twelve ounces more of blood were taken in the same 
way. In the course of the day, the bandage around the arm got 
displaced ; this was not discovered for several hours, so that a 
considerable hemorrhage took place, but the convulsions did not 
return afterwards. From that moment the patient gradually re- 
covered under the use of sinapisms to the extremities, a potion 
composed of the tinctures of castor and amber, and sulphuric 
ether, and a drink made of infusion of cherry-laurel and orange 
flowers. On the third day he recovered his sight and entire con- 
sciousness, and on the eighth day was able to walk. 

That bleeding does not always produce such good effects, how- 
ever, is shown by the result of the following case which occurred 
to myself. A very stout and hearty girl, 12 years old, was seized 
with malignant scarlet fever, of which she was extremely ill from the 
3d to the 9th day. She then improved somewhat, but on the 12th 
day was attacked with general anasarca, unaccompanied, how- 
ever, with severe nervous symptoms, and which nearly disappeared 
on the 16th. From the 21st to the 25th day, she did very well. 
There was merely slight oedema of the face, and she sat up the 
greater part of the day in good spirits. At eight o'clock, on the 
evening of the 25th day, as she sat in an armchair, taking her tea, 



368 CEREBRAL CONGESTION. 

she said suddenly to her sister, " there is some one sitting on my 
arm," and her sister saw that on endeavouring to take Hold of a 
teaspoon, the hand no longer obeyed the will. Her speech then 
became mumbling, and she fell back in a slight convulsion. I 
saw her within half an hour from the beginning of the attack, and 
found her unable to speak, almost insensible, and slightly con- 
vulsed. I bled her immediately to the amount of twenty ounces 
from the arm, applied cold to the head, gave a purgative enema, 
and ordered a cathartic dose of calomel and jalap. In a few mo- 
ments after the bleeding she was attacked with terrific general 
convulsions. The bleeding was repeated in half an hour to the 
amount of at least sixteen ounces more, but without any effect. 
The convulsions continued with very slight intermissions for ten 
hours, when they ceased, and were followed by profound coma, 
and death in twenty-three hours from the onset of the nervous 
symptoms. No autopsy was made. 

I have only to add, in regard to the treatment of acute hydro- 
cephalus, the advice of M. Barrier, which is to employ, when the 
apoplectic nature of the disease, its coincidence with dropsical 
affections of other parts of the body, the sta e of the urine, and the 
antecedent history of the case, make the diagnosis clear, the treat- 
ment generally required by scarlatinous dropsy, that is to say, 
diaphoretics, diuretics, and hydragogue cathartics. He adds that 
as experience has seemed to show that bloodletting is useful, 
though hydrocephalus is not probably an inflammatory disease at 
first, we should be blamable not to resort to it. 



ARTICLE IV. 

CEREBRAL CONGESTION. 

It appears to me from the evidence of several of the highest au- 
thorities on the diseases of children, that cerebral congestion is of 
rare occurrence as an idiopathic and distinct affection in early life. 
To prove the truth of this statement, I have only to quote the 
opinions of some of the writers referred to. MM. Rilliet and 



GENERAL REMARKS. 369 

Barthez assert (t. i, p. 649) that they have found in children dying 
of different diseases, and who had presented no cerebral symp- 
toms, congestion precisely similar to what they found in others, 
who had exhibited more or less dangerous idiopathic or secondary 
nervous symptoms. " Some patients," they remark {Loc. cit. 
p. 650), " it is true, who presented us with examples of cerebral 
hyperemia, had had well-marked nervous symptoms. Thus we 
have met with the anatomical characters of congestion in young 
subjects who had perished with convulsions, in those whose sick- 
ness had been accompanied by violent delirium, and in others 
who, in the course of scarlet fever, for instance, had been seized 
with nervous symptoms. But, on the other hand, we have met 
with a nearly equal number of patients who had died under the 
same circumstances, but in whom the cineritious and medullary 
substances preserved their usual colour, and the pia mater was not 
injected. What are we to conclude from these facts ? Most as- 
suredly that we ought not to attribute to cerebral hyperemia 
any considerable part in the production of the symptoms." At 
page 651 they say : " The most important practical point is, in 
fact, to determine whether it is possible to recognise cerebral con- 
gestion in a child by special and characteristic symptoms, and 
whether we ought as a consequence to prescribe a particular form 
of treatment. We acknowledge, on our part, that we find it impos- 
sible to describe any symptoms peculiar to that condition, and con- 
sequently to formulate a treatment." In the article on convulsions 
(t. ii, p. 281) they state that in some of their patients they found 
no traces of congestion, and add that eclampsia is sometimes (a well- 
known fact) connected with an ansemic state of the brain. "What 
are we to conclude from these opposite facts, if it be not that con- 
gestion plays but a secondary part in convulsions?" They coin- 
cide in opinion with the authors of the Compendium, who suppose 
that the congestion found in patients who have died with convul- 
sive symptoms, is generally the effect and not the cause of the 
convulsions. They do not deny, however, that a sudden conges- 
tion of the brain may produce a convulsive attack, and quote cases 
from other writers. 

I believe it to be a very common opinion in this country that 



370 CEREBRAL CONGESTION. 

most of the nervous symptoms (delirium, somnolence, coma, con- 
vulsions, etc.) which occur in the course of many of the diseases of 
childhood, depend chiefly upon a congested condition of the nervous 
centres, and also that many practitioners refer most of the cases 
of eclampsia of children to the same cause. I am glad, therefore, 
to call the attention of the profession to this point, and to place 
before it the opinions of some of the recent distinguished authorities 
in regard to it. 

The authors of the Bibliotheque du Med. Prat, are of opinion 
that it is very rare to meet with true pathological and idiopathic 
congestion of the brain, either in the first or second infancy (t. vi, 
p. 118). M. Barrier states that primary or secondary hyper- 
emias are sometimes a cause of convulsions, and that such cases 
are the most dangerous of their kind. He also states that in rare 
instances congestion assumes a more menacing character, similar to 
that which is more frequently met with at an advanced age, mean- 
ing the apoplectic form. M. Valleix asserts (Loc. cit. t. ix, p. 259) 
that " cerebral congestion is a disease almost unknown in in- 
fancy." 

M. Rilliet, in the paper on simple meningitis quoted in the article 
on that disease, states as his opinion that the cases attended with 
dangerous cerebral symptoms, which resemble exactly those oc- 
curring at the commencement of meningeal inflammation, which 
terminate rapidly in death or recovery, and in which the only 
lesions found after death are congestion of the brain and its mem- 
branes, ought to be regarded as dependent upon congestion, though 
he thinks it difficult to determine positively whether they are in 
fact the result of that condition, or whether they are not merely 
the forming stage of meningitis. 

Dr. Chas. West, of London, whose recent publications upon the 
diseases of children are the most valuable, it seems to me, that the 
English press has afforded us, treats of congestion of the brain in 
children as a very important and frequent condition of disease. 
{Led. on the Dis. of Inf. and Childhood. Lond. Med. Gaz. June 
4th, 1847.) I shall chiefly follow Dr. West in my remarks upon 
this subject, for though there can be no doubt, from the researches 
of the French observers above quoted, that its importance has been 



SYMPTOMS. 371 

much exaggerated, and that its real influence in the production of 
the symptoms generally ascribed to it is very imperfectly under- 
stood, yet a considerable number of cases occur in practice, espe- 
cially favourable ones, which it is very difficult to understand or 
to know how to treat except upon the time-honoured supposition of 
congestion. 

Dr. West treats of congestion of the brain under two heads, as 
active or jussive. By the former is meant the kind of congestion 
occurring under the influence of a cause which greatly increases 
the flow of blood to the head, and to this class belong, for instance, 
the head symptoms which often usher in the eruptive fevers ; by 
the latter is understood the kind depending on an impediment to the 
reflux of blood from the brain, to which belong, for example, the 
convulsions which occur in a fit of hooping-cough. 

Active congestion may occur during the process of dentition, or 
may result from exposure to the sun, or from blows upon the 
head ; passive congestion may be the result of a mechanical im- 
pediment to the return of blood from the brain, as the pressure of 
an enlarged thymus, or of enlarged and tuberculous bronchial 
glands upon the jugular veins, or of languid circulation depending 
upon want of pure air, or of nourishing and sufficient food. Dr. 
West states that intense cerebral congestion is not a very unusual 
consequence of the disturbance of the circulation at the outset of 
the eruptive fevers. He says that convulsions and apoplectic 
symptoms sometimes come on suddenly in these cases, and may 
terminate fatally in less than twenty-four hours : after death 
" the brain is found loaded with blood, but all the other organs of 
the body are quite healthy." I would merely remark here, that it 
seems to me very doubtful whether the nervous symptoms just 
alluded to, ought not to be regarded as the result of the presence 
in the nervous centres of a diseased and vitiated blood, rather than 
of congestion. That congestion does not always produce them is 
shown by the statement of Rilliet and Barthez, (Loc. cit. t. ii, p. 
620,) in regard to the cerebral symptoms of scarlet fever, " that a 
more or less marked sanguine congestion (of the cerebro-spinal 
apparatus) is the only alteration generally but not always found ; 
and sometimes the congestion is not more marked than in other 



372 CEREBRAL CONGESTION. 

diseases in which there had been no cerebral symptoms." With 
these remarks I shall pass on to the consideration of the symptoms 
generally ascribed to congestion occurring under other circum- 
stances, as those taking place in the course of the eruptive fevers 
will be treated of under the head of those affections. 

Dr. West states that cerebral congestion may come on suddenly 
with very alarming symptoms, or it may be preceded for a few 
days by general uneasiness, by a disordered state of the bowels, 
generally but not always consisting of constipation, and by peevish- 
ness. " The head by degrees becomes hot, the child grows rest- 
less and fretful, and seems distressed by light, or noise, or sudden 
motion, and children who are old enough sometimes complain of 
their head." Vomiting generally occurs repeatedly, sometimes 
before any other symptoms, and is a very important one. The 
fever varies greatly as to its violence, though the pulse is usually 
much and permanently quickened, and if the skull be still unossified, 
the anterior fontanelle is either tense and prominent, or the brain 
is felt and seen to pulsate forcibly through it. The sleep is dis- 
turbed, the child often waking with a start, and there is often occa- 
sional twitching of the muscles of the face or the tendons of the 
wrist. 

The child, Dr. W. remarks, may recover from these symptoms 
without any medical interference, or the case may become aggra- 
vated and terminate in acute hydrocephalus, or again, the conges- 
tion may increase and cause the following symptoms. Under the 
latter condition, " the countenance becomes heavy and anxious, 
the indifference to surrounding objects increases, and the child lies 
in a state of torpor or drowsiness, from which, however, it can at 
first be roused to complete consciousness." The bowels generally 
continue constipated, and the vomiting seldom ceases, though it 
may be less frequent. The pulse is usually smaller than before, 
and often irregular in its frequency, though not intermittent. 
" An attack of convulsion sometimes marks the transition from 
the first to the second stage ; or the child passes, without any 
apparent cause, from its previous torpor into a state of convulsion, 
which subsiding, leaves the torpor deeper than before. The fits 
return, and death may take place in one of them, or the torpor 



CEREBRAL HEMORRHAGE. 373 

growing more profound after each convulsive seizure, the child at 
length dies comatose." 

This second stage is usually of short duration, as death gene- 
rally occurs, unless relief be afforded by appropriate treatment, 
within forty-eight hours from the first fit, " though no graver lesion 
may be discovered afterwards than a gorged state of the vessels 
of the brain and its membranes, and perhaps a little clear fluid in 
the ventricles and below the arachnoid." Occasionally, however, 
recovery takes place contrary to all expectation, after these symp- 
toms have continued but slightly modified, for days or even weeks. 

Acute congestion is to be treated like simple meningitis, with 
bloodletting, cathartics, calomel, cold applications to the head, 
baths, revulsives, low diet, and confinement to a cool, dark cham- 
ber. It is useless to repeat here, what has already been said in 
our remarks upon the treatment of meningitis. 

In passive congestion the treatment should consist, according to 
Dr. West, of careful local depletion, if the case will bear it, and 
in strict attention to the diet and state of the bowels. He recom- 
mends mercury and chalk to correct the bowels when they are out 
of order. If the case be associated with diarrhoea and bad nutri- 
tion, he recommends that extract of bark, with a few drops of sal 
volatile, or of the compound tincture of bark be given two or three 
times a day. Farinaceous food, he remarks, is not usually well 
digested when nutrition is much impaired, and he recommends 
milk and water, or milk and water with isinglass, or veal tea. 



ARTICLE V. 

CEREBRAL HEMORRHAGE. 

I shall consider hemorrhage of the brain under two heads, that 
of the substance, and of the membranes, the former of which is 
usually designated as cerebral, and the latter as meningeal apoplexy. 
Both these forms of hemorrhage are of rare occurrence in child- 
hood compared with other diseases of the brain, and with their 
frequency during adult life and old age. Of the two kinds, that of 

32 



374 CEREBRAL HEMORRHAGE. 

the meninges is the most common. I desire to state, before begin- 
ning the consideration of this subject, that I do not expect to be 
able to give an accurate account of it, since this is impossible in 
the present state of knowledge in regard to diseases of children. 
I shall endeavour, however, by careful examination of recent 
authorities, to present as faithful a picture as is possible under ex- 
isting circumstances. 

Definition ; frequency ; forms. — By cerebral apoplexy or hemor- 
rhage is understood an effusion of blood into the substance of the 
brain. By meningeal apoplexy or hemorrhage is understood an 
effusion of blood between the dura mater and cranium, into the 
cavity of the arachnoid membrane, beneath the arachnoid, or 
in the meshes of the pia mater. Cerebral hemorrhage is a very 
rare affection in childhood. This is proved to be the case by the 
facts that Rilliet and Barthez met with only eight cases in their ex- 
tensive experience, and that M. Barrier saw but one in 576 cases 
of disease of all kinds. Meningeal apoplexy is of more frequent 
occurrence, since Rilliet and Barthez report eighteen cases. M. 
Barrier met with one case of this form in the 576 cases referred to. 
Dr. West (Lond. Med. Gaz. June 18th, 1847, p. 1062,) says he 
has only twice met with distinct extravasation of blood into the 
substance of the brain in children. 

Hemorrhage into the substance of the brain occurs in two different 
forms ; one in which the effused blood is contained in a cavity 
caused by a laceration of the tissue of the organ, and designated 
apoplexy in a cavity ; and the other in which the blood is effused 
in a multitude of little points of different sizes, and designated 
capillary apoplexy. 

- In meningeal hemorrhage the blood may, as we have stated, be 
effused between the dura mater and the bone. This form, how- 
ever, is very rare, so rare indeed, that several writers deny its 
existence. It is proved, however, to have occurred, by a case re- 
ported by Rilliet and Barthez, which is the only one they have 
met with. In by far the most common form of the disease, the 
blood escapes into the cavity of the arachnoid membrane. Of this 
form the authors just quoted report 17 cases, while, according to 
the authors of the Bibliotheque du Med. Prat., (t. vi, p. 193,) the 



causes. 375 

effusion always occurs in this situation. That this is not invariably 
correct, however, is proved by the case of effusion exterior to the 
dura mater already referred to, and by the fact that it does some- 
times take place beneath or in the meshes of the pia mater. The 
latter class is very rare however in proportion to the cases in 
which the hemorrhage occurs within the cavity of the arachnoid. 
Rilliet and Barthez did not themselves meet with a single instance of 
that kind, but they quote two from other writers ; and M. Valleix 
refers to a memoir by M. Prus, in which others are given. It 
appears, therefore, that in the great majority of instances, the ex- 
halation takes place within the cavity of the arachnoid membrane. 
Causes. — The causes of cerebral hemorrhage are very obscure, so 
much so indeed, that some writers have not attempted to ascertain 
them. They appear to be the same in both forms of the affection. 
Amongst the ascribed causes are the sudden disappearance of erup- 
tions of the scalp, observed in two cases by Rilliet and Barthez, in one 
of which this effect is stated to have been produced suddenly by medi- 
cal treatment, while in the other it followed the application of poul- 
tices to a favous eruption upon the same part. The disease is stated 
by M. Legendre to have followed in one case a violent fit of anger. 
It is said also to have been produced by various causes which 
acted as impediments to the circulation. The obstacle may be 
situated within or exterior to the cranium. To the first class 
belong cases in which the sinuses and large venous trunks of the 
head have been found obstructed by coagula of blood, or by the 
pressure of tumours, generally of a tubercular nature ; to the 
latter, those in which there is compression of the superior vena 
cava by enlarged and tubercular bronchial ganglions, or obstruction 
of the abdominal circulation by the pressure of hypertrophied 
organs, and chiefly of the spleen or liver. Another cause is thought 
to be the existence of confirmed cachexia and general debility from 
any diseased condition whatever, in which the blood having become 
thin and lost its plasticity escapes from the vessels with great 
facility. This last condition is one which almost always exists in 
connexion with the causes cited as acting through the agency of 
obstruction to the circulation, and tends of course to augment their 
dangerous effects. 



376 CEREBRAL HEMORRHAGE. 

In some instances the hemorrhage occurs in the healthiest and 
most vigorous constitutions, and cannot be accounted for in any- 
way. 

It appears that meningeal apoplexy is most frequently met with 
in very young children, according to Rilliet and Barthez between 
the ages of one and two and a half years, whilst M. Legendre did 
not meet with a single case after three years of age in 248 autop- 
sies. Cerebral and ventricular hemorrhage, on the contrary, are 
much more common after three years of age than before, which is 
just the reverse of the law in regard to meningeal effusion. 

Anatomical lesions. — The description of the lesions of hemor- 
rhage into the substance of the brain, need not detain us long, as 
they are much the same as those observed in the adult. When 
the blood is effused into cavities, (apoplexy in cavities,) the 
latter are usually small in size, seldom exceeding from one to two 
thirds of an inch in diameter, though in rare cases they have been 
found much larger. The cavity is formed by a laceration of the 
substance of the brain, and is filled with soft, dark coagula, or 
sometimes with fluid blood ; the walls of the cavity consist some- 
times of the substance of the brain, which may be of a rosy colour 
and natural consistence, or yellowish and softened, while in other 
instances they are formed of more or less numerous points of 
capillary apoplexy. The capillary form of effusion occurs in the 
shape of a number of points scarcely so large as the head of a small 
pin, and of a dark or brownish colour, which contrasts strongly 
with that of the cerebral tissue. These points evidently consist of 
true coagula, which are sometimes surrounded by small yellowish 
areolae. The substance of the brain around the effusion is either 
white, firm, and perfectly healthy, or softened and of a whitish, 
reddish, or yellowish colour. The capillary effusions are generally 
limited within a space of from a third of an inch to an inch and a 
half in size, but have been found scattered over a large portion of 
the hemispheres. 

Both forms of hemorrhage are much more common in the cere- 
brum than cerebellum, and occur more frequently on the left than 
right side. In addition to the sanguine effusion there is generally 



ANATOMICAL LESIONS. 377 

considerable congestion of the pia mater, of the venous sinuses, or 
of the substance of the brain itself. 

In describing the lesions of meningeal apoplexy, I shall confine 
my remarks to the effusion which occurs into the cavity of the 
arachnoid, which is, as we have already remarked, by far the 
most frequent form of the disease. 

The appearances presented by the cavity of the arachnoid into 
which the effusion has taken place vary greatly in different cases, 
according to the age of the child, quantity of the exhalation, 
and period of time which may have elapsed between the acci- 
dent and death of the patient. It is very uncommon to find pure, 
liquid blood, though it has been met with. In most instances 
there is a bloody serum mixed with thin, reddish coagula, con- 
tained in a soft and very delicate membrane lining the internal 
surface of the arachnoid. Sometimes the effusion is thin, limpid, 
and more or less yellowish in colour, while at other times it is 
thick and brownish or chocolate coloured. In some rare cases it 
is perfectly transparent and colourless. The fluid, in whatever 
state it exists, appears to be the result of transformations under- 
gone by the effused blood. The solid portion of the blood or clot, 
is found either in the condition of more or less recent coagula, or 
changed into false membranes, which sometimes resemble very 
closely the arachnoid itself, and sometimes a true fibrous membrane. 
The coagula are found in the form of thin membranes, varying 
between one t>r two lines, and an inch and a half or two inches in 
size. They are thickest generally in the centre, where they 
measure between a fifth of a line and two lines, and are brownish 
or greenish in colour, and of variable consistence according to their 
age. These coagula may exist upon any portion of the brain, but 
according to Rilliet and Barthez are most frequently met with 
upon its convex surface. 

The coagula just referred to undergo, in some instances, a curious 
change, of which I shall give a short description. In the course 
of time the fibrinous portions of the blood are deposited upon the 
internal surfaces of the cavity of the arachnoid, in the form of a 
new membrane. When death occurs soon after the onset of the 
attack, the parietal layer of the arachnoid is found to be completely 

32* 



378 CEREBRAL HEMORRHAGE. 

lined with this membra ni form production, whilst the visceral or 
cerebral layer is covered by it only in certain points. When the 
case has lasted a longer time, on the contrary, the visceral as well 
as parietal layer of the arachnoid may be covered with the new 
production, and when this happens there is formed a true sac or 
cyst, destitute of opening, which lines the whole interior of the 
arachnoid and contains within it bloody serum and coagula. At 
first this new membrane is reddish in colour, elastic, and of a 
stronger texture than might be supposed from its apparent thinness 
and softness. Its thickness is generally about a tenth of a line. 
At a later period the walls of the cyst become so thin and trans- 
parent, that they have been mistaken for the arachnoid itself. 
They differ, however, from the latter, in being rather less trans- 
parent and thin, and particularly in the circumstance of presenting 
numerous arborizations. When death occurs at this stage, which 
M. Legend re (whose description I chiefly follow) calls the second 
period, or that of complete organization of the cyst, the external 
surface of the latter is found to adhere intimately to the parietal 
portion of the arachnoid membrane, by very delicate cellular tis- 
sue, though not with so much force but that it may be detached by 
traction. The internal portion of the new membrane, on the con- 
trary, which is lubrified by the serosity of the arachnoid tissue, is 
very slightly adherent to the layer of that membrane covering the 
brain. 

So long as the cyst formed by the new membrane, or as it is 
called by Rilliet and Barthez, the pseudo-arachnoid membrane, 
contains an amount of fluid sufficient to keep its surfaces separated, 
its cavity is single. When, on the contrary, the walls of the cyst 
have come into contact, either because of the partial absorption of 
the contained fluid, or because the fluid has accumulated at the 
lowest points, or wherever there is the least resistance, the cavity 
becomes multilocular in consequence of the cohesion of its walls 
at certain points. 

The size of the cyst varies exceedingly. Sometimes it covers 
the greater part of the convex surface of one hemisphere, some- 
times the whole, and in other instances extends to the base, forming 
in that case a nearly complete shell for the whole brain. The 



ANATOMICAL LESIONS. 379 

quantity of fluid varies in different cases. Sometimes it amounts 
only to a few large spoonfuls ; in others to one or two, or eight or 
nine ounces, and in one case observed by Rilliet and Barthez to 
upwards of a pint on each side, or more than a quart in all. In 
most instances the hemorrhage occurs into both halves of the 
arachnoid membrane, so that there is a cyst for each hemi- 
sphere. More rarely it occurs only on one side. 

In the second stage, and when the effusion is very large, which 
rarely happens except in very young children and prior to ossifica- 
tion of the fontanelles or sutures, the symptoms resemble those of 
chronic hydrocephalus. The vault of the cranium is enlarged by 
the unnatural prominence of the frontal and parietal bones ; the 
sutures are more open than usual, and the anterior fontanelle is dis- 
tended and protuberant. When the effusion occurs thus early in 
life, before complete ossification of the skull, the brain does not 
appear compressed or flattened, as it does when the disease occurs 
at a later period. 

The visceral portion of the arachnoid is often thickened, opaque, 
and more resisting than natural. The pia mater is frequently in- 
filtrated with a good deal of serosity, which sometimes has a gela- 
tinous appearance. When death has occurred in the first stage of 
the disease, the brain usually presents signs of hyperemia. The 
veins on the surface of the hemispheres are enlarged, the cortical 
substance is of a bright rose-gray colour, and the medullary portion 
dotted over with drops of blood. Sometimes the cellular substance 
beneath the arachnoid is slightly infiltrated with serosity, at other 
times not. The ventricles contain a very small quantity of fluid. 

It seems pretty clearly established that the effusion is the result 
of exhalations from the membrane, caused by frequently re- 
peated determination of blood to the head, independent of rup- 
ture of vessels. In some rare instances, however, as in one wit- 
nessed by M. Legendre, the effusion is the result of rupture." In 
the case observed by him, death took place in twelve hours from 
the attack, and the left hemisphere was found covered with a layer 
of coagulated blood, which had escaped from a ruptured vein. 
{Bibliolh. die Med. Prat. t. vi, p. 192.) 

Symptoms ; duration. — The symptoms of hemorrhage into the 



380 CEREBRAL HEMORRHAGE. 

substance of the brain in the child are, as a general rule, extremely 
obscure and uncertain, though in some few cases that have been 
observed, they were as characteristic as those which occur in 
adults. In obscure cases the chief symptoms that have been 
noticed were restlessness, delirium, headache, violent fever, grind- 
ing of the teeth, and after a time complete abolition of the intelli- 
gence, fixity of the eyes, invariable dilatation of the pupils, sterto- 
rous respiration, and general insensibility. Of three cases reported 
by M. Valleix {Clinique des Mai. des Enf.) the nature of the 
disorder was easily diagnosticated in one by the existence of com- 
plete hemiplegia, while in the two others, the only marked symp- 
tom was complete immobility. The only certain symptoms of the 
disease, therefore, would be a sudden attack of hemiplegia, either 
as the primary symptom, or following coma or convulsions, and 
lasting for at least several days. An attack of general paralysis 
would not be by any means so certain, as this may exist in several 
other diseases of childhood. 

In a case which came under my charge, I believe the attack to 
have been one of apoplexy of this kind. A girl, two years and a 
half old, apparently in the enjoyment of excellent health, was sud- 
denly, and without ascertainable cause, attacked with violent 
general convulsions and entire insensibility, which lasted with very 
slight remissions of the convulsive movements, but without any 
return of consciousness, for twelve hours. At the end of that time 
the convulsions ceased entirely, and she very soon regained her 
consciousness, remaining merely peevish and languid. She was, 
however, completely hemiplegic on the left side, so that she could 
neither rise in bed, nor turn towards the right side. The paralysis 
diminished rapidly, but gradually, so that at the end of three days 
she could sit up in bed, and in a few weeks, was perfectly well. 
This child remained well, with the exception of rather unusual 
excitability, and some peevishness of temper, for three years, when 
she died of scarlet fever. No autopsy could be made. 

The obscurity which exists in these cases will be clearly under- 
stood by any one who will read two examples of this kind given 
by Dr. West. (Loc. cit. p. 1062.) 

With a short quotation from the work of Rilliet and Barthez, I 



SYMPTOMS. 381 

shall pass on to the subject of meningeal apoplexy. These authors 
remark, (t. ii, p. 54,) in speaking of this affection, that " cerebral 
symptoms have been observed to exist, but of so unusual a cha- 
racter, and so different from what have been assigned by writers 
to apoplexy, that they could not lead to a diagnosis of the 
disease." 

I shall describe the symptoms of the meningeal form of hemor- 
rhage under two heads ; first, as they present themselves in the 
acute, and, second, as they occur in the chronic, or second stage 
of the affection. 

Unfortunately, the symptoms of the acute or first stage are not 
much more certain and distinct than those of cerebral hemor- 
rhage. The disease may begin with fever, and some convulsive 
movements, or as happened in a case reported by M. Valleix, with 
violent general convulsions. Vomiting sometimes occurs at the 
beginning, but is usually very slight. It is difficult to know whe- 
ther headache exists at the early age at which this disease com- 
monly occurs. The convulsive movements generally affect par- 
ticularly the eyes, and are followed by some degree of strabismus. 
The appetite is lost from the first ; the thirst is moderate ; there is 
no constipation. Soon after the symptoms described, appear per- 
manent contractions of the hands and feet, which are followed by 
attacks of tonic or clonic convulsions, during which sensibility and 
intelligence are abolished. Between the attacks of convulsions 
there is somnolence, which, though slight at first, becomes more 
marked as the case goes on. The attacks of convulsions become 
I more and more frequent as the case progresses, until at the last they 
are nearly constant. The tonic convulsions affect the limbs and 
trunk both, but particularly the former, whilst the clonic spasms 
i occupy sometimes one side of the body, sometimes the upper extre- 
! mity alone, and at other times the whole body, but even then are 
' usually stronger on one side than on the other. Paralysis is rarely 
noticed in the disease; it occurred only in one out of nine cases 
I observed by M. Legendre, and in one out of seventeen observed by 
' Rilliet and Barthcz. 

Dr. West remarks (p. 1061) : " The absence of paralytic symp- 
toms, however, is not the sole cause of the obscurity of these cases, 
but the indications of cerebral disturbance, by which they are at- 



882 CEREBRAL HEMORRHAGE. 

tended vary greatly in kind as in degree. The sudden occurrence 
of violent convulsions, and their frequent return, alternating with 
spasmodic contraction of the fingers and toes in the intervals, ap- 
pear to be the most frequent indications of the effusion of blood 
upon the surface of the brain. I need not say, however, that such 
symptoms, taken alone, would by no means justify you in inferring 
that its effusion had taken place." Dr. West adverts particularly 
to the fact that apoplexy in the child is particularly apt to occur in 
those who are weakly and feeble, and gives to this form of the 
disease the appellation of cachectic form of cerebral hemorrhage. 

The chronic form presents most of the symptoms which exist 
in acquired chronic hydrocephalus from serous effusion into the 
ventricles. The cranium is very large in proportion to the face ; 
the sutures are not ossified ; there is strabismus, with dilatation of 
the pupils ; the sense of sight is generally but not always retained ; 
the face loses its expression ; if the child was old enough at the 
moment of the attack to have shown signs of intelligence, the 
latter is found to diminish, rather than increase, and sometimes to 
be lost entirely, as the size of the head augments ; and the child 
is apt to utter loud cries, particularly during the night. The 
cutaneous sensibility is in general neither lost nor diminished. The 
power of motion usually remains, though it was entirely lost in 
one case. The appetite and thirst persist. 

The duration of cerebral apoplexy is very irregular. In one 
case quoted by Rilliet and Barthez, it was a quarter of an hour ; 
in another an hour ; in a third forty-eight days ; and in one re- 
ported by M. Valleix, in a very young infant, recovery was nearly 
perfect in a little less than two months, when the child was seized 
with pneumonia and died. 

The duration of meningeal apoplexy is also irregular. Accord- 
ing to M. Legendre, all the recent cases seen by him in the Chil- 
dren's Hospital died in from eight to twelve days, apparently rather 
from intercurrent diseases than from the primary affection itself, 
whilst cases occurring in subjects placed in better hygienic con- 
ditions, and not attacked with intercurrent affections, passed into 
the second or hydrocephalic stage of the disease. The second 
stage lasted, according to the same author, in the four cases which 



DIAGNOSIS PROGNOSIS TREATMENT. 383 

he witnessed, from eight to thirty months, and then death was the 
result, not of cerebral symptoms, but of complications affecting the 
thoracic organs. 

Diagnosis. — The diagnosis of cerebral hemorrhage is, as I have 
already stated, very difficult, unless hemiplegia exist. When the 
case commences, as it often does, with convulsions, or with in- 
flammatory symptoms, it is often impossible to distinguish it from 
acute or tubercular disease of the brain. 

The diagnosis of meningeal hemorrhage is also very often ex- 
tremely difficult. Not unfrequently it. occurs in the course of 
other diseases, and is then entirely latent. In acute, primary 
cases, the most important and distinctive symptoms are the early 
age of the subjects, between one and three years generally ; the 
violent fever from the commencement, marked by full, frequent, 
and regular pulse ; the absence of constipation ; the frequency of 
the convulsive attacks, and particularly the permanent contraction 
with rigidity of the feet and hands. 

The diagnosis between the form of hydrocephalus which fol- 
lows meningeal apoplexy, and ventricular serous hydrocephalus, 
is exceedingly obscure. The only circumstance which seems to 
have any real value, is age. MM. Rilliet and Barthez state that 
they have never known a child of two years old, or younger, to 
die of ventricular serous hydrocephalus from tumours whether 
tubercular or not of the brain ; in all such cases the effusion has 
been the result of a sanguine exhalation. 

Prognosis. — The prognosis of both forms of the disease is very 
grave. It is impossible, however, to ascertain the prognosis with 
any certainty, so long as the symptomatology of the two affections 
is as obscure as we have found it to be. That cerebral hemor- 
rhage is susceptible of cure, however, is proved by the case re- 
ported by M. Valleix, already referred to, in which the child had 
nearly recovered, when it was seized with another disease which 
destroyed it. I have not been able to find any well-authenticated 
case of recovery from the meningeal form, though I cannot imagine 
why it may not be susceptible of cure, as any other sanguine 
effusion. 

Treatment. — The treatment must depend on the diagnosis of 
the case. In a sudden and severe attack, occurring in a strong and 



384 CEREBRAL HEMORRHAGE. 

hearty child, and in which the symptoms of sudden pressure on 
the brain are clearly marked, or even highly probable, it should 
be the same as that employed in the apoplexy of the adult, that is 
to say, antiphlogistic. The child ought to be bled from the arm, 
ankle, or external jugular as soon as possible after the invasion, 
and this can be done generally in private practice within an hour. 
I believe that general bleeding is a much more powerful remedy 
in itself than local depletion, and moreover, it has the immense 
advantage of being applicable instantly upon the arrival of the 
physician, who can perform, or ought to be able to perform, the 
operation of venesection himself, instead of sending to a greater 
or less distance for a bleeder, leecher, or cupper, to do what the 
interest of the patient requires should be done at once. When, 
however, it is impossible from any cause to employ venesection, 
we may substitute leeching or cupping. It is impossible to lay 
down positive rules as to the amount of blood to be taken, as 
this must depend on the age and strength of the child, and the im- 
pression made upon the symptoms by the detraction. In the case 
of the girl two years and a half old, already referred to, who was 
attacked suddenly while in good health with general convulsions 
and entire insensibility, I took three ounces from the ankles, and 
applied leeches twice, within twelve hours from the onset, taking 
about nine ounces of blood in all. At the end of twelve hours, 
and after the second leeching, she regained her consciousness per- 
fectly, but was hemiplegic on the left side. She recovered. 

As soon as bloodletting has been practised, or, if leeches are 
employed, while they are being used, cold applications should be 
made to the head, either by cloths, the ice bladder, or by pouring 
water from a height from a pitcher or kettle. At the same time, 
or as early as possible after the invasion, a dose of some purgative 
medicine must be given. The best is probably calomel, either alone 
or combined with jalap or rhubarb. If given alone, it ought to be 
followed in an hour or two by castor oil, infusion of senna and 
manna, salts, magnesia, or some active cathartic. If the symp- 
toms be very urgent, it is well to open the bowels still more 
speedily by a purgative enema. 

Counter-irritants are always useful adjuvants to the remedies 



TREATMENT. 385 

already mentioned. They should consist at first of mustard 
plasters applied to the extremities, and shifted from place to place. 
If the symptoms do not yield after proper depletion and the use of 
sinapisms for some hours, it is well to apply blisters to the calves 
of the legs, and to the nape of the neck. 

The diet must be very strict, and should consist only of barley 
or arrow-root water, for a few days. 

It ought to be remarked, however, that bleeding is not always 
proper in cases supposed to depend either upon cerebral or menin- 
geal apoplexy, for, as has already been stated, the effusion of blood 
occurs more frequently perhaps in feeble and weakly children, as a 
consequence of previous diseases, which have exhausted the forces 
of the constitution and occasioned a state of diffluence and dys- 
crasia of the blood, than in those of robust and plethoric health. 
In the former class of cases, depletion would of course be alto- 
gether inadmissible. Such was the character of two cases of 
meningeal apoplexy in children of five weeks and three years old, 
reported (Lgc. cit.) by Dr. West. Again, of eight cases of cerebral 
apoplexy observed by Rilliet and Barthez, four coincided with 
more or less general tubercular disease. In such cases as these, 
we must depend upon local depletion lo a very moderate extent, if 
at all, and upon the use of purgatives, cold applications, and 
counter-irritants. 

For the paralysis which follows apoplexy in children, I believe 
that the most important, and indeed the only treatment neces- 
sary, is attention to the general health of the patient, in order 
to give to nature time and opportunity to effect the absorp- 
tion of the clot, which has been thrown out into the substance 
of the brain, or the exhalation which has taken place into the 
cavity of the arachnoid membrane. When the disease assumes 
the chronic form, occasioning the kind of hydrocephalus we have 
described, there is little more to be done than to attend to the 
general health of the child, and to promote absorption of the fluid 
by the internal administration of diuretics, and the preparations 
of iodine. It has been proposed also to get rid of the fluid by 
tapping, as has been done in congenital hydrocephalus, and. in 
some cases of acquired chronic hydrocephalus. 



CHAPTER II. 

NEUROSES, OR DISEASES OF THE NERVOUS SYSTEM, UNATTENDED 
WITH APPRECIABLE ANATOMICAL ALTERATIONS. 

ARTICLE I. 

GENERAL CONVULSIONS, OR ECLAMPSIA. 



iM 



General remarks. — The word convulsions is a generic term 
applied to different forms of spasmodic disease, very dissimilar 
from each other in many of their characters. 

Writers make different classifications of convulsions according 
to their peculiar notions in regard to the nature and causes of those 
disorders. The best division is, it seems to me, that adopted by 
most French writers, who arrange them by their supposed causes, 
making three classes, idiopathic or essential, sympathetic, and 
symptomatic convulsions. The first two classes are unaccompanied 
by appreciable lesions of the nervous centres, while the third 
is called symptomatic, because it includes cases of convulsions 
which are the sign or symptom of an appreciable lesion of the m ^ 
cerebro-spinal axis, as for instance, those which occur in the i 
course of meningitis, tubercular disease, hydrocephalus, apoplexy, ; % 
etc. In idiopathic or essential convulsions, the cause of the | ^m, 
attack acts directly upon the nervous centres, while in those to j 
which the term sympathetic is applied the cause lies in the in- 
fluence or effect upon the brain or spinal marrow, of disease of 
some other organ ; to the latter class belong the convulsions 
which occur in the course of pneumonia, bronchitis, the eruptive 
fevers, etc. 

L shall not pretend to give an accurate account of symptomatic 
convulsions in this article, as they have already been treated of 






h 

irem 

tat 
nous 

lod] 

[k 



DEFINITION CAUSES. 387 

under the head of the different organic diseases of the brain in 
the course of which they occur. I shall refer to them in the 
present article only so far as may be necessary to elucidate the 
pathology, diagnosis, prognosis, and treatment of idiopathic and 
sympathetic convulsions. 

There is a form of eclampsia occurring in children, which 
I shall describe separately, as it differs in many of its cha- 
racters from ordinary convulsions. This is the disease known by 
the names of spasm of the glottis, thymic or Kopp's asthma, 
laryngismus stridulus, and eclampsia with suffocation. 

Definition ; synonymes ; frequency. — By convulsions is meant 
a condition of disease in which the muscular or locomotive inner- 
vation is deranged and perverted, so that the movements become 
irregular and automatic, and are no longer controlled by the will. 

The only synonymes which it is necessary to mention are epi- 
lepsia puerilis, insultus epilepticus, and eclampsia. The latter 
term, eclampsia, is, I believe, preferable to any other, and I would 
gladly introduce it instead of convulsions, which is too general a 
term to express the form of disease under consideration. 

The frequency of eclampsia is very great. It appears from Dr. 
Condie's tables that during the ten years preceding 1845, 2824 
children under fifteen years of age died, in this city, of convul- 
sions ; whilst, during the same time, 2583 died of infantile cholera, 
2154 of scarlatina, and 1592 of pneumonia, showing that accord- 
ing to the bills of mortality, eclampsia was the cause of a larger 
number of deaths than any other single malady. It must be re- 
collected, however, that a large number of these cases ought, in 
all probability, to have been returned under other titles, as many of 
them, no doubt, depended upon organic disease of the cerebro- 
spinal axis, and other acute local or general diseases. 

Predisposing causes. — Essential and sympathetic convulsions 
are much the most frequent before the age of seven years, which 
is the case also in regard to symptomatic convulsions, though the 
latter often occur after the age mentioned. Of 43 cases of convul- 
sions that I have met with, in which the age was noted, 12 oc- 
curred in the first year, 11 in the second, 9 in the third and fourth, 
and 11 between the fourth and ninth years of life. Dr. West 
[Lond. Med. Gaz. vol. iv, 1847, p. 884) states that according to 



388 ECLAMPSIA. 

the fifth report of the registrar-general, the deaths from diseases 
of the nervous system in the metropolis, under one year of age, 
hore a proportion of 33 per cent, to the deaths from all causes ; 
from the first to the third year, the proportion was 20'9 per cent. ; 
from the third to the fifth year, it was 20 per cent. ; whilst from 
the tenth to the fifteenth year, it was only 9*3 per cent. Again, to 
show the very great influence of age upon the predisposition to con- 
vulsions, Dr. West states, that within the first year, the deaths from 
convulsions constituted 74*2 per cent, of the total mortality from 
diseases of the nervous system ; between the first and third years, 
the proportional mortality from convulsions, in the total mortality 
from affections of the nervous system, was 27'1 per cent. ; between 
the third and fifth, it was 18-1 per cent; while between the tenth 
and fifteenth years, it had fallen to 2*7 per cent. 

Dr. West ascribes the great frequency of convulsions in early 
life to the predominance of the spinal over the cerebral system, 
and to the imperfect development of the brain. 

It is generally stated that convulsions are more common in girls 
than boys. Rilliet and Barthez, on the contrary, observed them 
most frequently in boys, and such has been my own experience, 
since of 44 cases that I have seen, 23 occurred in boys, and 21 in 
girls. 

It has been generally supposed that a delicate and nervous con- 
stitution, is a powerful predisposing cause to convulsive attacks. 
This has been denied, however, by several recent writers, whose 
observations are very careful and accurate. I am disposed to be- 
lieve that it is not so much a feeble or delicate constitution that 
predisposes to convulsions, as it is one characterized by a highly 
susceptible, irritable, and nervous temperament, which often exists, 
in my opinion, in connexion with an apparently healthy and 
vigorous physical organization. Of 48 children in whom I have 
seen convulsive attacks, these occurred more than once in 5. Of 
the 5, 4 presented every appearance of strong and vigorous health, 
with the exception that when labouring under any kind of sickness, 
as dentition, indigestion, the fever accompanying simple angina, 
and in two the invasion of measles, they immediately became ex- 
tremely restless and irritable, or heavy and drowsy, and at a very 
early period, and sometimes with very little warning, were seized 



CAUSES SYMPTOMS. 389 

with convulsions. The fifth child was puny and feeble until after 
the completion of the first dentition, when it grew strong and 
hearty. The number of convulsions varied in the different sub- 
jects. In 1 there were five different attacks, in another four, in 2 
there were three, and in 1, two. They all recovered and are still 
living : 2 at the age of seven, 2 at that of six, and 1 four years old. 
They are all free, at present, from anything like epileptic disease. 

It is generally believed that the predisposition to convulsions is 
sometimes hereditary. I have remarked in regard to this point, 
that several children in the same family sometimes surfer from the 
disease, and that the nervous temperament to which I alluded 
above, appeared in some instances to have been inherited by the 
child from its parents. 

The exciting causes of convulsions are exceedingly numerous 
and dissimilar. Amongst the causes of essential convulsions are 
cited vivid moral emotions, violent pain, high temperature, ex- 
posure with the head uncovered to the sun, and sudden exposure 
to cold. In many cases, however, the exciting cause cannot be 
detected. The exciting causes of sympathetic convulsions may 
be almost any of the diseases incident to childhood. Amongst 
them I will cite as probably the most frequent, hooping-cough, 
pneumonia, scarlatina, measles, violent fever from any cause, den- 
tition, and indigestion. 

Of 48 cases of convulsions that have come under my notice, 
I have regarded only 3 as essential, whilst 32 were sympathetic, 
and 13 symptomatic. Of the 3 essential cases, I could not detect 
the exciting cause in any. Of the 32 sympathetic cases it was 
scarlet fever in five ; pertussis and indigestion each four ; pneu- 
monia and simple angina each three ; cholera infantum, dysentery, 
measles, bronchitis, and dentition, each two ; enteritis one ; an 
over-dose of castor oil (3vi) given to a young child with a slight 
cholera, one ; and lastly, fcecal accumulations in the large intestine 
in one. 

Symptoms. — Prodromic symptoms. — It has been asserted by 
some writers that most attacks of convulsions in children are 
preceded by prodromic symptoms, which indicate to the expe- 
rienced eye their approach. This docs not agree exactly with my 

33* 



390 ECLAMPSIA. 

own experience, at least in regard to the essential and sympathetic 
forms, since of the cases of the former variety, well-marked pro- 
dromes did not occur in any, and of 32 of the latter, they were 
observed only in four. It is proper to state, however, that I have 
frequently observed symptoms in children suffering from various 
ailments that seemed to me to threaten an attack of eclampsia, 
and which have been dissipated by proper preventive treatment. 

The precursory symptoms of idiopathic and sympathetic con- 
vulsions are difficult to describe because of their variable nature. 
They consist in general, however, of whatever indicates a highly 
disordered condition of the nervous system. The most marked 
symptoms are unusual drowsiness, excessive irritability, a peculiar 
physiognomical expression, general tremors, and the drawing of 
the thumbs into the palms of the hands, or rigid flexion of the toes. 
The drowsiness which precedes an attack of eclampsia, is almost 
always accompanied with some restlessness. The sleep is light 
and easily disturbed ; the child moves and turns, or starts and 
moans; often it seems to have frightful dreams, and will scream 
out or wake suddenly, bewildered and terrified, and when roused 
is generally exceedingly irritable, crying violently or fretting at ihe 
slightest contrariety, or without cause. The face, and particularly 
the eye, often exhibit a peculiar expression altogether different from 
their usual appearance. The expression which has most struck 
me, and which I have seen on several occasions, is a fixed and 
staring look, lasting but for an instant, as though the child were 
looking intently at some object, while in fact it is gazing at vacancy ; 
at the same time the expression is entirely without meaning. The 
child seems in fact, for a moment, to be in a state of extasis. In 
some instances a sardonic smile is seen to pass over the counte- 
nance just before the attack. The tremors or tremblings alluded 
to above, occur both in the sleeping and waking state, but particu- 
larly in the former. Flexion of the thumbs and toes has been 
noticed by different observers, but is, I believe, a sign rather of 
the approach of symptomatic, than of essential or sympathetic con- 
vulsions. 

The precursory symptoms of symptomatic convulsions will de- 
pend on the nature of the disease in the course of which they occur. 
Not unfrequently the convulsions occur at the very outset of the 



SYMPTOMS OF THE ATTACK. 391 

disease of the brain or spinal marrow, when of course there will 
be no prodromic symptoms whatever. According to Dr. Marshall 
Hall, (Diseases of the Nervous System, p. 149,) the first and most 
frequent sign showing that, the excito-motory system is becoming 
complicated in diseases of the brain is vomiting, after which come 
strabismus, a contracted state of the muscles of the thumbs or 
fingers, or some unequivocal spasmodic or convulsive affection of 
the respiratory muscles, or of the muscles of the limbs. 

Symptoms of the attack. — With or without the precursory symp- 
toms just described, the convulsive movements generally begin in 
the eyes ; which, for a moment, are fixed and staring, and then 
drawn obliquely upwards under the upper lid, so that the white 
portions of the balls alone are visible for an instant between the 
partially open lids. During the attack the eyes are rarely fixed 
in one position, but are constantly agitated in various directions, 
from side to side, or upwards and downwards ; very often there is 
the most violent strabismus ; the eyelids are sometimes open, at 
others shut ; the pupils may be contracted or dilated. The 
muscles of the face next enter into contraction, and occasion the 
most hideous contortions of the features. The mouth is distorted 
into various shapes, the lips often covered with a whitish or 
sanguinolent froth, and the jaws tightly clinched together by 
tonic spasms, or agitated by convulsive movements, so as to pro- 
duce grinding of the teeth. The trunk of the body generally be- 
comes rigid and stiff from tonic contractions of its muscles, though 
it also is sometimes variously contorted by clonic convulsions. 
The head is usually strongly retracted upon the trunk, but in other 
instances is drawn to one side, or violently rotated. The muscles 
about the front of the neck enter into action, and alternately elevate 
and depress the larynx ; the tongue, when it can be seen, is ob- 
served to be moved in different directions, and is sometimes caught 
between the teeth and severely bitten. The extremities, particularly 
the superior, are more violently convulsed than any other parts. 
The fingers are drawn into the palms of the hands, the fore-arms 
are flexed and extended upon the arms by short, rapid and generally 
rhythmic movements, the hand is quickly pronated and supinated 
upon the arm, or finally the whole upper extremity is twisted and 
distorted into various positions, which it is impossible to describe. 



392 ECLAMPSIA. 

The inferior extremities undergo similar movements, but almost 
always in a less degree than the upper. The respiration during 
the attack is irregular, sometimes suspended by rigid spasm of the 
respiratory muscles, and sometimes accelerated. A spasmodic 
contraction of the larynx, producing noisy inspirations, has been 
noticed by several writers. We shall find when we come to con- 
sider the nature of the disease, that Dr. Hall is of opinion that 
more or less complete closure of the larynx is the most important 
feature of the convulsive crisis. The face is often livid and deeply 
congested, especially when the respiration is embarrassed ; the 
head is hot, whilst the extremities are cold ; the pulse becomes 
large and full, or frequent and small, and sometimes cannot be 
counted in consequence of contraction of the muscles of the 
fore-arm. The face is not always however congested. I have 
sometimes seen it perfectly white, while the convulsions were severe, 
and the child profoundly insensible. The action of the heart is 
tumultuous, and sometimes irregular or intermittent. When the at- 
tack is very violent, the urine and faeces are occasionally discharged 
involuntarily, but these are rare symptoms. Deglutition is seldom 
impossible even in the severest fit. In severe, and especially long- 
continued attacks, intellectual consciousness, and general and 
special sensibility are all abolished. In milder cases, though con- 
sciousness is destroyed, some of the special senses still respond to 
irritants, whilst in still slighter cases, the intelligence also is more 
or less preserved. 

Convulsions are not always as we have just described them, 
general. They may be circumscribed or partial, affecting one 
side of the body more than the other, or one side alone, or a single 
arm. Sometimes they attack the eyes only. The inferior ex- 
tremities are rarely affected alone. Of the partial convulsions the 
most frequent is that in which some part of the face and upper 
extremities are attacked. In this form of the disease, the disorders 
of the circulation and respiration, the congested tint of the face, 
froth upon the lips, and derangements of intelligence and sensi- 
bility, are much less strongly marked than in general attacks. 

The duration of an attack of eclampsia concerns both the length 
of the convulsive crisis, and the continuance of the disposition to 



SYMPTOMS — NATURE. 893 

renewals of the crisis. Both of these are very uncertain. I 
have known the attack to last in all its violence eight hours and 
a half in one case, and twelve in another, and it is said to have 
lasted much longer in some instances. When the spasmodic 
movements continue during a long period, they are almost al- 
ways interrupted by remissions. As a general rule, the duration 
is much shorter than the periods above mentioned, — from a few 
minutes to half an hour. When the attacks cease and recur as 
they often do several times in a day, they leave the patient during 
the interval in a state of more or less perfect consciousness or 
somnolence, restlessness or delirium, or finally of coma. The 
period during which the disposition to recurrence continues, de- 
pends principally upon the cause of the convulsions. If this con- 
tinues in action, they will be apt to return until it is removed. 

Idiopathic and sympathetic convulsions generally consist of a 
single attack, though there are sometimes several, which occur at 
intervals of several hours, or one or two days. Sympathetic con- 
vulsions usually occur either at the beginning or termination of the 
disease which they complicate, and much less frequently during its 
middle period. Of 23 cases of this form observed by myself, com- 
plicating measles, scarlet fever, pneumonia, cholera infantum, simple 
angina and dysentery, in which the period was carefully ascertained, 
they occurred at the invasion alone in 9, at the termination alone in 
9, at the middle period alone in 3, and at the invasion and termina- 
tion both in 2. It is curious to remark, that all the cases in which 
they occurred at the invasion or in the middle period, recovered ; 
whilst all those in which they occurred only at the termination, or 
at the invasion and termination both, proved fatal. 

Rilliet and Barthez state that half the cases of symptomatic con- 
vulsions observed by them, occurred at the commencement of the 
encephalic disease. This form seldom consists of a single crisis ; 
the attacks on the contrary, are repeated from time to time. The 
authors just quoted state that whenever the convulsive attacks have 
recurred repeatedly within an interval of a few days, they have 
proved symptomatic of disease of the brain. 

Nature of the disease. — It seems to me that the only plausible 
and satisfactory explanation of the pathology of convulsions in 
children, is that afforded us by the physiological doctrines in regard 



394 ECLAMPSIA. 

to the nervous system, set forth by Dr. Marshall Hall in his writings. 
Dr. Hall says {Diseases and Derangements of the Nervous System, 
p. 145), " That the whole class of convulsive diseases consists of 
affections of the true spinal system, there is no longer any doubt. 
But these diseases do not all originate in this system." All con- 
vulsive disorders are, according to this doctrine, affections of the 
true spinal or excito-motory system. The causes of these dis- 
orders may be of incident origin, acting upon excitor nerves ; of 
centric origin, seated in the brain or spinal marrow ; or of reflex 
origin, acting upon reflex or motor nerves. They are called, 
therefore, according to their causes, central or centric, when they 
depend on disease of the nervous centres ; centripetal, when they 
are excited through excitor nerves ; and centrifugal when they 
depend on disease of the motor nerves. Dr. Hall ascribes great 
importance to the condition of the glottis in convulsions. He says 
(p. 323), in speaking of epilepsy, " The second symptom is a 
forcible closure of the larynx, and expiratory efforts, which suffuse 
the countenance, and probably congest the brain with venous blood." 
At page 327, he says, " A spasmodic affection of the larynx has 
obviously much to do in this disease (epilepsy), as well as in the 
crowing inspiration or croup-like convulsion of infants ; so much, 
indeed, that I doubt whether convulsion would occur without clo- 
sure of this organ." In describing the croup-like convulsion or 
laryngismus stridulus (p. 180), he says : " I must repeat the ob- 
servation that the respiration is actually arrested by the closure of 
the larynx ; and that there are forcible expiratory efforts only, or 
principally, in the actual convulsion." 

In a recent publication Dr. Hall says : " without closure of the 
larynx, extreme laryngismus, and the consequent congestion of the 
nervous centres, there could, I believe, be no convulsion ! This 
closure of the larynx must be complete, in the affection under con- 
sideration, (laryngismus stridulus,) as in all others, before convul- 
sion can take place." (Braith. Ret. from Lancet, June 12, 1847, 
p. 609.) 

It is easy to comprehend the mode of production of sympathetic 
convulsions by reference to these doctrines. They evidently de- 
pend upon morbid impressions conveyed to the true spinal system 



NATURE DIAGNOSIS. 395 

through the excitor nerves, which have their origin in the diseased 
organs. Thus it is easy to understand why inflammation of the 
parenchyma of the lung in pneumonia, of the bronchial mucous 
membrane in bronchitis, of the mucous membrane of the bowel in 
entero-colitis or dysentery, or of the pharynx in angina ; why the 
pressure of a tooth upon an inflamed gum during dentition, the 
presence of a foreign body, as newspaper, or crude food, or fecal 
accumulations in the stomach or intestines, should produce a de- 
gree of irritation in excitor nerves, sufficient, when transmitted to 
the spinal centre, to occasion the convulsions we have been con- 
sidering. 

It is more difficult to explain the mode in which continued 
fevers, measles, scarlatina, &c, give rise to convulsions. To me, 
however, it seems readily explained by the morbid effect produced 
upon the nervous centres by the blood, which is known to be more 
or less changed, in these affections, from its healthful condition. 

The explanation of the production of idiopathic or essential 
convulsions is not always so easy, because we are sometimes 
unable to detect any cause, either centric, centripetal, or cen- 
trifugal, to account for the excitation of the spinal system. It 
seems probable, however, that they must depend, like those of the 
sympathetic form, upon some unhealthful, and therefore irritating 
condition, acting upon the excito-motory system of nerves. The 
cause may be so slight as to escape the notice of the physician, 
and yet sufficient to produce a convulsive crisis in a child predis- 
posed to eclampsia. It may be an unnoticed dentition, some 
undigested food in contact with the stomach or intestines, or accu- 
mulations of unhealthy fecal substances in the intestines. When 
convulsions have followed a vivid mental emotion, as passion or 
vexation, they are evidently a result of the influence of that con- 
dition upon the nervous centres. Acute pain, which is said to have 
occasioned essential eclampsia, as well as exposure to violent heat 
or severe cold, must produce their effects through their action upon 
incident excitor nerves. 

All symptomatic convulsions belong, of course, to the class of 
centric diseases. These need no further remarks. 

Diagnosis. — There are two important points to be considered 



396 ECLAMPSIA. 

in treating of the diagnosis of eclampsia: the diseases with which 
it may be confounded, and the causes which may have produced 
the convulsions, or, in other words, their distinction into essential, 
sympathetic, and symptomatic. 

The only disease with which eclampsia is likely to be con- 
founded, is epilepsy ; the mistake could only be made when 
the former is violent, and accompanied and followed by uncon- 
sciousness. In epilepsy, however, the invasion is more sudden, 
the convulsions are accompanied with greater rigidity, there is 
always frothing at the mouth, the duration of the crisis is shorter, 
and it is generally followed by more marked stupor. If the con- 
vulsive attack have occurred under the influence of an appreciable 
cause, if the parents are not epileptic, and if the child is very im- 
pressionable, it is probably eclampsia. Again, the younger the 
patient, the more likely is the case to be one of eclampsia ; whilst 
if the child is approaching towards puberty, if the attacks are fre- 
quently repeated, and yet followed by complete restorations to 
health in the interval, the disease is much more likely to prove to 
be epilepsy. 

The diagnosis of the form of the attack, whether idiopathic, 
sympathetic, or symptomatic, is exceedingly important, as upon 
this must depend in great measure the prognosis and treatment. 
It is often very difficult, and sometimes impossible, to determine at 
the moment, to which class the convulsions belong. The most 
difficult points in the diagnosis are the following : first, when a 
child previously in good health, is suddenly seized with the dis- 
ease, to determine whether it is essential ; whether it is sympa- 
thetic and occasioned by disease which, up to this instant, has been 
latent, or by the invasion of some one of the acute local diseases, 
or of one of the continued fevers ; or lastly, whether it is symp- 
tomatic, marking the invasion of a disease of the cerebro- spinal 
axis : second, when the convulsion occurs in the course of a dis- 
ease not implicating the nervous centres, to determine whether it 
is merely sympathetic of that disease, or whether it is symptomatic 
of the invasion of an intercurrent affection of the brain or spinal 
marrow. 

It is impossible, for want of space, to treat of all these points in 



DIAGNOSIS. 397 

detail. The enumeration of them, however, will be useful in 
calling the attention of the reader to their importance. 

An essential convulsion is only to be distinguished by careful 
study of the antecedent history and present condition of the pa- 
tient. If, after a thorough examination of all the organs, no dis- 
eased point can be detected, and if the child recover perfectly from 
the convulsion, we must conclude that the case has been an idio- 
pathic one, in which the cause is beyond our reach. I am dis- 
posed to believe, however, as has already been stated, that in most 
such cases there has been a source of irritation in some of the 
organs of the body, which has acted as the excitant to the excito- 
motory system, and which, if we could but detect it, would war- 
rant us in classing the case amongst sympathetic convulsions. 

The sympathetic and symptomatic forms of eclampsia are to 
be diagnosticated by the same careful attention to the antecedent 
history and present condition of the child. If the latter be teeth- 
ing at the time of the fit, and there be no other cause to explain the 
attack, and nothing in the consecutive symptoms to render such an 
explanation inadmissible, we may refer it to that condition. I 
may remark merely, that, as a general rule, eclampsia depending 
entirely upon the irritation of dentition, is seldom either violent or 
long-continued, and the return to consciousness and health is 
speedy. The probable dependence of the attack upon indigestion 
is to be ascertained by the absence of other causes, and by our 
learning upon inquiry that the child had eaten of some indigestible 
substance within a few hours or a day before the attack. Its de- 
pendence on intestinal accumulations is to be arrived at by the 
same negative or exclusive method, and by learning that the 
patient is usually, or has been of late, of a constipated habit. 

When the attack occurs in the course of some other disease, as 
pneumonia, enteritis, pertussis, scarlatina, or measles, it is almost 
certainly sympathetic. It may possibly, however, be indicative of 
an intercurrent attack of cerebral disease. This can be determined 
only by attention to the consecutive phenomena. If the attack be 
short, and soon followed by complete restoration to consciousness, 
it is in all probability sympathetic. If, on the contrary, the con- 
vulsive crisis be long and severe, if the recovery from it be slow 

34 



398 ECLAMPSIA. 

and imperfect, if it be followed by violent agitation, somnolence or 
coma, or by some persistent lesion of motility, there is every 
reason to fear an attack of disease of the brain. 

Sympathetic convulsions occurring at the invasion of different 
local or general diseases, are to be distinguished only by observa- 
tion of the symptoms that follow the crisis, which will be those 
belonging to the particular malady whose approach has caused the 
attack of eclampsia. 

Symptomatic eclampsia is characterized by various signs of en- 
cephalic disorder, which rapidly succeed the convulsive attack. 
The most important of these are severe and continued headache ; 
diminution or exaltation of general or special sensibility ; dilatation 
or contraction of the pupils ; irregular movements of the eyes ; 
flexion or stiffness of some of the limbs, or of the fingers or thumbs ; 
disordered intelligence ; or the symptoms which have already been 
described in the articles upon the diseases of the brain. 

Prognosis. — The prognosis of essential convulsions must de- 
pend on the nature of the cause, and violence of the attack. 
When the cause has been slight, or one which soon ceases to act, 
or can be readily removed, the prognosis is much more favourable 
than under opposite conditions. If the convulsive crisis is short 
and of moderate severity, if the pulse and respiration are but 
slightly disturbed, if there be but little congestion of the face, and 
no stertor, there is every reason to hope a successful issue in the 
case. Of the three cases of this class that I have seen, two re- 
covered and one died. 

Sympathetic is more dangerous than essential eclampsia, but 
much less so than symptomatic. The prognosis will depend 
chiefly on the nature of the disease which it complicates, and on the 
stage of that disease at which it occurs. Thus, in scarlatina convul- 
sions are almost always fatal, in measles much less so, and in other 
diseases in various proportions. They are much more apt to ter- 
minate unfavourably where they occur after the malady which 
they complicate has been in progress several days. This is a 
remark made by various authors, and I have already stated that 
of 23 cases of this form, in which I carefully ascertained the 
period of their occurrence, there were 9 at the invasion, all of 



PROGNOSIS TREATMENT. 399 

which ended favourably ; 3 at the middle period which also re- 
covered ; two both at the invasion and at a later period, both of 
which were fatal ; and 9 after the cases had been progressing for 
a considerable time, all of which proved fatal. In addition to these 
important elements for making the prognosis, we must consider, 
also, the duration and degree of violence of the paroxysrh, the 
state of the patient after the fit as to his cerebro-spinal functions, 
and lastly the age and constitution of the child. 

The prognosis of symptomatic convulsions must depend very 
much upon that of the disease of which they are the symptom. It 
may be stated as a general rule, that, like those of the sympathetic 
class, they are less dangerous when they occur at the beginning, 
than a later period of the disease. They are always, however, 
very dangerous. Of 13 cases that I have seen, 11 were fatal. 

Treatment. — I shall confine my remarks upon the treatment of 
eclampsia to the essential and sympathetic forms of the disease, 
having already treated of that of the symptomatic form in the 
articles upon the cerebral diseases which give rise to them. 

It seems to me that the treatment of eclampsia in children may 
be simplified by attention to two distinct conditions of disorder, 
which appear to exist in every case. These are the condition of 
morbid irritation or derangement of the excito-motory system of 
nerves, and the cause which occasions that derangement. The 
condition of irritation or disease of the true spinal system exists 
in all cases, and is always the same, differing only in degree and 
extent ; whilst the morbid cause of that irritation differs in each 
case, being in one dentition, in another pain, in another constipa- 
tion, in others pneumonia or indigestion, pleurisy or angina, 
scarlet fever, or measles, fright, or other violent emotions. If this 
view of the subject be correct, it is clear that in treating a case of 
convulsions, we have to attend to the two morbid conditions referred 
to, and I shall be careful, therefore, in the course of my remarks, 
to treat of the remedies most proper for the removal of the cause, 
whatever it may be, which acts as the irritant to the spinal system ; 
and of those proper to subdue or allay the deranged condition of 
the spinal system and the effects of that derangement. 

There are some general rules to be followed in the treatment 



400 ECLAMPSIA. 

of convulsions which apply to all cases, and of these I shall first 
speak. They are, to place the child in a large, well-ventilated 
room, if such can be procured ; if it have been seized in a 
little close room, where the atmosphere is dense and impure, re- 
moval to another room, or exposure to fresh air before an open 
window, has sometimes sufficed to terminate the crisis. At the 
same time the clothes of the child should be loosened, in order to 
prevent all constriction, and if necessary, taken off, to allow of a 
careful examination of the whole body. I believe that it is a good 
rule always to place the child, no matter what the cause of the 
convulsion may be, if it be at all a severe one, in a warm bath 
(96° or 97° F.) This has frequently proved an efficient remedy, 
according to my experience. It is easily procured in most cases, 
and I am quite confident that I have never known it do harm, 
though I have used it in almost every case. The patient should 
be kept in the bath some ten, fifteen, or twenty minutes, or until 
the convulsive movements cease ; when taken out it is most con- 
venient, and at the same time useful, to envelope it in a small, 
light blanket, or flannel, for a short time, before the clothes are 
readjusted. 

If the convulsion occur in a strong and vigorous subject ; if it 
be violent, and accompanied by deep red, or still more livid flush 
of the face, and distension of the veins of the head and neck ; if 
it last more than a few minutes, or is repeated after short intervals 
of quiet, I would in all cases, without hesitation, recommend the 
use of bloodletting. The detraction of blood is called for, in my 
opinion for the same reasons as in puerperal convulsions, and in- 
deed in every violent convulsive attack ; to save the nervous cen- 
tres from the effects of the paroxysm, which are in all severe cases, 
excessive congestion, and in some, fatal effusions. It is useful, 
moreover, by means of the sedative and relaxing influence which it 
exerts upon the whole economy, and particularly upon the sanguine 
and nervous apparatuses. I think, therefore, that we may lay it 
down as a rule, to employ bloodletting in all instances, except those 
in which the convulsion depends upon an anemic condition, and in 
which it is contraindicated by a naturally feeble or by a debilitated 
state of the constitution ; in those which it is clearly unnecessary 



TREATMENT. 401 

from the slight severity or short duration of the attack ; or those 
which occur in the course of other diseases, and particularly at 
their termination, and in which a resort to it is rendered evidently 
improper by the circumstances of the concomitant affection. The 
quantity of blood to be taken, and the method, must depend on the 
circumstances of the case. It is best to bleed generally whenever 
this is possible, as the operation is much more speedily performed 
than local bleeding, and because the sedative and relaxing effects 
of the detraction upon the economy are more powerful. The 
blood may be taken either from the arm or jugular vein. We 
must be guided as to the quantity by the age and constitution of 

j the patient, the violence and duration of the paroxysm, and the 
cause of the attack. In a strong, hearty child, two or three years 
of age, in whom the attack is violent, and produced by some cause 
not likely to continue long in action, and thereby exhaust the 
strength, we may take from four to six ounces at the first bleeding, 

I and should this fail to exert an influence upon the paroxysm, a 
rather smaller quantity may be taken in one or two hours after- 
wards. In younger children, or those who are somewhat feeble 
or delicate, the amount drawn ought to be less. When general 
bleeding cannot, from any cause, be employed, we may resort to 
cups and leeches to the temples or back of the neck, or, as advised 
by some of the French writers, to more distant parts. 

I believe it is useful in all cases of essential and sympathetic 
convulsions, which resist the employment of a warm bath and 
bleeding, and also when bleeding cannot be or is not resorted to, 
to make use of an emetic of some kind. The act of vomiting alone 
is often sufficient to break up a paroxysm of convulsions which has 
resisted various other means. This I learned first from the advice 
of an old and experienced practitioner, who was in the habit of 
employing emetics in all cases of eclampsia of children, and I have 
since seen it tested on several occasions. Dr. Hall recommends 
the induction of vomiting in the treatment of the paroxysm of the 
croup-like convulsion or laryngismus stridulus, and as a means of 
prevention in epilepsy. In the former he employs irritation of the 
fauces by tickling with a feather ; in the latter, ipecacuanha. He 
says that a new mode of action is induced in the true spinal system 

34* 



402 ECLAMPSIA. 

by the act of vomiting, so that the disposition to closure of the 
larynx, and expiratory efforts, is exchanged for sudden acts of in- 
spiration. The emetic which I employ, is ipecacuanha. It may 
be advantageously combined with tartar emetic in the case of a 
vigorous child, especially if no depletion have been used. The 
employment of emetics is, of course, particularly called for, when- 
ever there is a suspicion of the presence of undigested food or of 
foreign bodies in the stomach. 

In addition to warm baths, bleeding, and emetics, cold applica- 
tions to the head will be found proper and useful in nearly all 
cases which are of any considerable violence. Their use would 
be improper, however, when the surface is pale, the features con- 
tracted, and the pulse small and feeble ; but, whenever the skin, 
especially that of the head, is deeply coloured and turgid, and the 
pulse full and strong, they ought to be employed from the be- 
ginning. While the child is in the bath, its head may be 
wrapped in a cloth wet with ice- water ; or after it has been 
removed, cold water may be poured from pitchers or a tea-kettle 
upon the same part. If the latter is done, enough should be em- 
ployed to prevent the sudden reaction which inevitably takes place 
when but a small quantity is used. During the after treatment of 
the case, the cold applications ought to be continued so long as the 
head remains unnaturally heated. 

The administration of a purgative dose is proper and useful in 
many cases of convulsions ; particularly when it is found upon 
inquiry that the child has been constipated prior to the attack ; 
when it is suspected that the bowels may contain crude food or 
some foreign body ; when it is desirable to produce an evacuant 
effect in a strong plethoric child, or a derivative action from the 
brain, and when the attack is attended with violent determination 
of blood towards that organ. The best purgative in severe cases 
occurring in hearty children is calomel. It is advantageous because 
of its easy administration, its speedy operation, and the powerful 
sedative influence which it exerts upon the whole economy. The 
dose should be from three to six grains, according to the age. It 
ought to be followed in one or two hours by some other cathartic, 
which may be either castor oil, rhubarb, jalap, or salts. The best 



TREATMENT. 403 

of all is castor oil if it can be given. When the attack is slight 
or the patient weak and delicate, castor oil is particularly ap- 
plicable, as it operates with so little irritation to the intestine. 
Whatever the remedy may be, it should be given only in such 
quantity as to produce complete evacuation of the bowels and a 
moderate derivation to those organs, without the risk of occasion- 
ing a decree of irritation sufficient to increase the disturbance of 
the nervous system already existing. 

In many cases of eclampsia it will be found that purgative 
enemata are of great service. They may be administered imme- 
diately before or after the bath, and not unfrequently have the 
effect of stopping the paroxysm. They may consist of water 
holding in suspension or solution castile soap, common salt, 
molasses, castor oil, or sweet oil. [f the first fails to operate in 
ten or fifteen minutes, another or even a third ought to be 
given. 

Revulsives are of the utmost importance in the treatment of 
convulsions. They should be employed from the very first, or 
immediately after the use of the bath. In slight attacks, they 
alone are often sufficient to suspend the paroxysm, or at least 
the fit often ceases under their use. Mustard is the most 
useful and convenient form of application in the great majority 
of cases. It may be used either in the form of sinapisms, which 
are to be shifted from place to place, or in that of the foot-bath. 
When sinapisms are used, they should always be covered with 
gauze or fine muslin, to avoid the danger of leaving any of the 
mustard upon the skin after they are taken off. I once saw very 
bad ulcerations upon the feet of a child from the neglect of this 
precaution. In the hurry and bustle of the moment, the feet were 
not washed when the plasters were removed, and the mustard that 
remained produced vesications which ulcerated. In obstinate 
attacks, the revulsives ought to be reapplied from time to time, 
taking care to shift their position in order to avoid vesication. 

Antispasmodics are highly recommended by some writers upon 
the disease, and particularly by M. Brachet, who appears to have 
used with great effect the oxide ot zinc in combination with extract 
of hyoscyamus. I have but little experience in regard to their 



404 ECLAMPSIA. 

use, but confess myself indisposed to resort to them except after 
the employment of the means already detailed ; during the intervals 
between the fits, when these occur from time to time ; and as a 
means of prevention in children threatened with the disease. There 
can be no doubt, from the evidence adduced in regard to their 
effects, and from what I have myself seen of the influence exerted 
by valerian upon the convulsive phenomena of acute cerebral 
diseases, that they have a considerable power of allaying the 
disorder of the locomotive apparatus present in all convulsive 
affections. As a means of prevention therefore, as adjuvants to 
other remedies, and in children of very nervous, irritable tempera- 
ment, and delicate constitution, in whom it is improper to use 
the more powerful agents already detailed, I would advise a re- 
course to substances of this kind. The ones most highly recom- 
mended are valerian, oxide of zinc, assafaetida, and camphor. Of 
these, valerian is the only one which I have employed, and this but 
to a slight extent. It is best given in the form of the fluid extract, 
of which from five to ten drops may be administered in water, to 
a child two years old, every half hour or hour, until several doses 
have been used, after which it ought to be suspended for a while 
or given in smaller quantity. M. Brachet gave the oxide of zinc 
in combination with extract of hyoscyamus, to the amount of at 
least two grains of the former and four of the latter in the twenty- 
four hours, divided into four, eight, or twelve doses. A dose was 
given every two or three hours, and when the symptoms were 
very violent, the first two or three were repeated at much shorter 
intervals. M. B. says, speaking of this remedy, ( Traite Prat, 
des Convulsions dans PEnfance. Deux. Edit. p. 402-3,) " I always 
found it to produce quiet ; but whilst the cause remained, the quiet 
was only momentary, and the remedy seemed to have produced no 

effect." " This remedy does not destroy the cause (of the 

convulsion), but it allows time to treat it by calming the nervous 
erethism." 

Opium is a remedy which requires much care and discrimina- 
tion in its employment, but which in certain conditions of the 
disease, is of the greatest service. It should rarely be given 
while there remains any evidences of considerable determination 



TREATMENT. 405 

of blood to the brain, but when this condition does not exist, or 
after it has been removed by bloodletting, and the use of revulsives, 
opium often proves very useful in allaying irritability and restless- 
ness, which themselves seem to keep up a disposition to return 
or continuance of the convulsive phenomena. Somnolence also, 
and still more, coma, likewise contraindicate the use of opium. 
Dr. Eberle thinks he has seen much advantage obtained from 
frictions over the spinal region, with a mixture of equal parts of 
oil of amber, laudanum, and spirits of camphor, particularly in 
very young infants. 

I shall here conclude my remarks upon the general treatment of 
eclampsia, and proceed to make some observations on the conduct 
to be pursued under particular circumstances. 

It is always highly important for the direction of the treatment, 
to discover the cause of the attack. This is sometimes very easy, 
while in other instances it is exceedingly difficult, and not unfre- 
quently, impossible. If the attack occur in the course of some 
acute disease, as pneumonia, angina, enteritis, or dysentery, or 
during the progress of one of the eruptive diseases, the diagnosis 
of the case is, as a general rule, very easy. If, on the contrary, 
it occurs at the commencement of one of these affections, the 
diagnosis will be much more difficult, unless indeed the symptoms 
! of the concomitant disease have already declared themselves, or 
do so very soon after the convulsion. The treatment in such cases 
should be that laid down in our general remarks, modified, however, 
by the requirements of the particular disease during the course of 
which the eclampsia occurs. 

When the attack occurs suddenly in a child previously in good 
health, or who had been merely slightly ailing for a few hours, the 
detection of the cause is still more difficult. The most probable 
causes, under such circumstances are, however, dentition, indiges- 
tion, intestinal disorder, or the approach of an acute general or 
local disease. It is easy to determine by inquiry of the attendants, 
and by examination of the mouth, whether the child is teething or 
not. As a general rule, the convulsions which depend solely on 
the process of dentition, are slight, and last but a short time. In 
all the instances that I have seen, in which such was the only 



406 ECLAMPSIA. 

cause to be detected, the attack was of this nature. The treatment 
in such instances is to lance the gums, if they are swelled and in- 
flamed over the advancing teeth ; to use warm baths, and to admi- 
nister enemata. These simple means will seldom fail when 
eclampsia depends on the process of dentition alone. But when, 
on the contrary, there is present indigestion, intestinal accumula- 
tions, or enteritis, as often happens during dentition, the case be- 
comes more serious, and requires, in addition to the treatment 
above described, one directed to the particular coexisting morbid 
condition. 

The existence of indigestion as the cause of the attack, can be 
discovered only by ascertaining with great care the diet of the 
child during the previous days. If it appear that something of 
an indigestible nature has been eaten within a short time, and if, 
at the same time, it be impossible to detect any more evident or 
probable cause for the attack, we should have a right to conclude 
that it depends upon indigestion. Under these circumstances the 
proper treatment is the immediate use of the warm bath, and the 
earliest possible administration of an emetic of ipecacuanha. The 
operation of the emetic may often be hastened by tickling the 
fauces with a quill. If the paroxysm be very severe and long- 
continued, bleeding ought to be resorted to. 

The presence of intestinal accumulations as the cause of the 
paroxysms may be inferred, when it is found upon inquiry that the 
patient has been constipated for some days, or that the stools have 
been scanty and hard, or scanty and very offensive ; when the ab- 
domen is distended and hard, and the distension is ascertained by 
palpation and percussion, not to be merely tympany ; and, lastly, 
when there is no more evident cause for the attack. In such a 
case the particular treatment is the use of purgatives and enemata, 
in addition to the other means detailed. 

The dependency of the attack on the approach or commence- 
ment of some acute general or local disease, can be inferred only 
from a very careful examination of the antecedent and present 
phenomena of the case. One of these may be suspected as the 
cause when we can account for the occurrence of the convulsion 
on no more reasonable supposition ; when neither dentition, indi- 



TREATMENT. 407 

gestion, nor intestinal irritation exist. It is scarcely likely that a 
convulsion could be occasioned by any of the acute thoracic or 
abdominal affections, unless the disease had already gone far 
enough to allow a careful examination of the different rational and 
physical symptoms, to determine its existence. Perhaps the most 
difficult cases to diagnosticate, are those which occur at the begin- 
ning of the eruptive fevers. Even here, however, a careful search 
for the prodromic symptoms of the disease, a watchful observance 
of the condition of the patient in and after the paroxysm, will 
generally lead to a correct opinion within a few hours, or after a 
day, and sometimes at the moment of the attack. Of the eruptive 
diseases, scarlet fever is much the most apt to be accompanied by 
convulsions at the onset, and in that disease the remarkable ra- 
pidity and activity of the pulse, the state of the fauces, the coryza, 
heat of skin, and early appearance of the eruption, will generally 
enable us to understand the cause of the convulsion at a very early 
period. 

The treatment of sympathetic eclampsia depending on acute 
thoracic or abdominal disease, should be that which is proper for 
the particular malady which they complicate, with the addition of 
warm baths, revulsives, antispasmodics, and, after depletion, of 
opium, in the form of Dover's powder combined with nitre. 
The management of the convulsions which complicate the eruptive 
fevers, will be specially treated of in the articles on those maladies. 



ARTICLE II. 

LARYNGISMUS STRIDULUS. 

Definition ; synonyrn.es ; frequency. — Laryngismus stridulus 
belongs to the class of neuroses. It is characterized by crowing 
inspirations, or by momentary suspensions of the act of respira- 
tion ; these attacks occur suddenly, and at irregular intervals, are 
-of short duration, cease suddenly, and are unaccompanied by 
cough, or other signs of irritation of the larynx. If the disease 
progresses, it is associated with other convulsive symptoms, as 



408 LARYNGISMUS STRIDULUS. 

strabismus, distortion of the face, carpo-pedal spasms, or general 
convulsions. 

It is " the peculiar species of convulsion" of Dr. John Clarke ; 
the inward fits of Underwood ; the spasm of the larynx or glottis 
of Marsh ; the laryngismus stridulus of Good ; the croup-like 
convulsion of Dr. Marshall Hall ; child-crowing ; the spasme de 
la glotte of the French writers ; and the thymic asthma of the 
Germans. It is not mentioned by Dewees. It is described by 
Eberle under the title of carpo-pedal spasms. 

The frequency of the disease seems to vary in different countries. 
In France it would appear to be rare. Rilliet and Barthez speak 
of having seen but one case ; and state that they are acquainted 
with only one other, published by M. Constant in the Bulletin de 
Therapeutique. M. Blache, (article Nevrose du Larynx, Diet, de 
Med. t. xvii, p. 590,) adverts very cursorily to one case. Valleix, 
(Guide du Med. Prat., Art. Asthme Thymique,) doubts its exis- 
tence as a distinct disease. In Germany, on the contrary, it 
would seem to be a rather frequent disease. In England it can- 
not be very infrequent, since Merriman says it is by no means 
uncommon. Copland, (Stridulus Laryngic Suffocation in 
Children, Diet, of Pract. Med.,) speaks of numerous cases that 
he has seen, and states that he has had as many as three under 
treatment at the same time. Ley speaks of having met with con- 
siderably above twenty cases. Dr. Marshall Hall remarks that 
" within the short space of one month, I have seen five cases of 
croup-like convulsion." 

I do not think that it is a common disease in Philadelphia, though 
it is certainly not extremely rare, since I have seen one fatal case 
myself, and know of the existence of two others, and of one case 
of recovery. 

Predisposing causes. — Age. — It is generally acknowledged that 
the disease occurs most frequently during the period of the first 
dentition, though it has been known to exist as late as six or seven 
years of age. Of 20 cases (17 collected by authors, and three by 
myself), in which the age is given, 9 were six months or less of 
age, 6 between six months and a year, 3 between one and two 
years of age, 1 of two, and 1 of four years of age ; so that of the 



CAUSES NATURE. 409 

20, 15 were under one year. It is evident, therefore, so far as 
these cases go, that the majority occur within the first, and very 
few after the second year. 

Sex. — It is most frequent in the male sex. Of 49 cases (45 from 
authors, and 4 by myself), 38 occurred in boys, and 1 1 in girls. 

Constitution. — Authors who have written on the disease, gene- 
rally express the opinion that it is most frequent in delicate and 
feeble, and especially in scrofulous constitutions. It is nevertheless 
acknowledged also that it sometimes occurs in the most healthy 
and vigorous subjects. It not unfrequently attacks several chil- 
dren in a family. Ley quotes four instances from other writers, 
in which three children in each family had the disease, and in 
one all three died. He states that his own experience fully con- 
firms this fact. 

Nature and exciting causes ; forms. — Much difference of opinion 
has prevailed in regard to the nature and exciting causes of laryn- 
gismus stridulus, since the disease has attracted the particular 
notice of the profession. Kopp and other German authors ascribe 
it to compression of the respiratory organs by enlarged thymus 
gland, while others of that nation, and some of the English and 
French writers, class it amongst the neuroses. Dr. Hugh Ley 
supposed it to depend on compression of the par vagum nerves by 
i enlarged cervical and bronchial glands. Dr. Marshall Hall con- 
siders it to be a disease of the reflex system of nerves. Amongst 
the French writers, Rilliet and Barthez regard it as a neurosis, 
consisting of spasm of the glottis ; Valleix doubts the propriety 
of regarding it as a distinct disease ; Blache (Diet, de Med. t. 
xvii, p. 584), speaks of it as a neurosis of the larynx, which may 
be either symptomatic or idiopathic. 

Before examining in detail the different opinions quoted above, 
which I propose doing, I will refer to the anatomical appearances 
of the malady, as observed by M. Herard, in several autopsies 
made by himself. (Bib. du Med. Prat. t. v, p. 319-320.) 

M. Herard states that he found the mucous membrane of the 
air-passages, as a general rule, perfectly healthy, presenting neither 
redness, inflammatory swelling, oedema, nor accidental products of 
any kind. The lungs were of the natural colour and density, and 

35 



410 LARYNGISMUS STRIDULUS. 

crepitant. They always presented one marked change from their 
natural condition, however, which was a very high degree of em- 
physema, more general and strongly marked than in any other 
disease. This alteration is believed to depend, as it does in hoop- 
ing-cough, upon the impediments to respiration which exist during 
the disease. 

The heart and great vessels of the thorax often, but not always, 
contained more blood than usual, as in asphyxia. 

M. Herard states that he has made very minute researches in 
regard to the condition of the nervous system, examining the brain 
and spinal marrow, the pneumogastric, recurrent, and diaphragma- 
tic nerves, and those of the extremities even to their terminations, 
without, however, finding important lesions in any case. He ex- 
cepts only serous effusion in small quantity, and evidently con- 
secutive, in the ventricles and particularly membranes of the 
brain, and slight venous congestion of the same kind. The tis- 
sues of the brain and spinal marrow retained their ordinary con- 
sistence, and presented neither redness nor softening. His re- 
searches in regard to the state of the thymus gland will be adverted 
to presently. 

I will now examine, as succinctly as possible, the different 
opinions which are advocated in regard to the causes of laryngis- 
mus stridulus. These may be classed, it seems to me, under four 
heads. 1. Enlargement of the thymus gland; 2. Enlargement 
of the cervical and bronchial glands ; 3. Organic disease of the 
cerebro-spinal axis ; 4. That which regards it as a simple neu- 
rosis, without appreciable anatomical alterations. 

1. Enlargement of the thymus gland. — That the disease is often 
coincident with, if not dependent upon, this cause, is proved by the 
observations of Kopp, Hirsch, Haugsted, Kyll, and others. Hasse 
(Pathol. Anat. Syden. Soc. Ed. p. 384), says there can be little 
doubt that it sometimes depends upon this cause. 

It seems to me that it has been clearly shown by M. Herard 
(Loc. cit. p. 320, 321), that the disease is entirely independent of 
any alteration of the thymus. That observer found that in six 
children between two and four years old, dying of the affection, 
the gland weighed between half a drachm and a drachm in five, 



NATURE AND EXCITING CAUSES. 411 

and four drachms and two scruples in the sixth. These cases 
alone show that the size of the gland varies greatly in different 
subjects attacked with the disease. M. Herard has examined the 
gland, with a view to the elucidation of this point, in sixty children 
dying with various diseases, between two and four }^ears of age, 
(the age of those who had died of the disease under consideration.) 
In fifty he found that it presented the same arrangement, colour, 
density, and weight, as in those who had perished with laryngismus 
stridulus. All of these subjects presented the same aspect ; they 
were pale, thin, and most of them exhausted by diarrhoea. In ten 
of the sixty, the gland was much more voluminous, weighing from 
two drachms to two and a half or five drachms, and in one in- 
stance an ounce and a quarter. The ten subjects upon which these 
observations were made died with different diseases, croup, acute 
laryngitis, asthma, meningitis, and varioloid. All presented the 
appearances of strong and vigorous health, and the one which 
presented the largest gland was very fat, and so robust that though 
only twenty-two months old, he looked to be three or four years. 
It results therefore from these researches, that the gland is liable 
to great variations of size, and that its size bears a very exact 
proportion to the force of the child, being small in those who are 
but slightly developed, or emaciated by chronic disease, and volu- 
minous in those who are vigorously constituted, or who have died 
of acute diseases. 

That the disease does not depend, at least in all cases, on this 
cause, is shown also by Haugsted {Arch, de Med. t. xxxiii, 1833, 
p. Ill), who reports the case of a girl, seven years old, in whom 
the gland weighed five ounces, and measured four inches long, 
and one and a half in thickness, without its occasioning the least 
difficulty of breathing of any kind. That it occurs in children in 
whom the gland is very small, is shown also by Caspari and Pa- 
genstecher (quoted by Hasse, Loc. cit.) 

2. Enlargement of the cervical and bronchial glands. — This 
condition as a cause of the disease, so strongly advocated by Dr. 
Ley, and adopted upon his authority by Kyll and Hasse, would 
seem from certain facts and arguments to be of doubtful agency. 

Thus, Mr. Wakely (quoted by Kerr) states that " he possesses 



412 LARYNGISMUS STRIDULUS. 

more than one case of tubercular affection in children, where the 
pneumogastric nerve has been completely flattened by the pressure 
of tubercles, without giving rise to any remarkable disturbance of 
the function of respiration." Dr. Hall doubts the correctness of 
this explanation of the phenomena of the disease, and says that if 
the contiguity of enlarged glands with the pneumogastric nerve 
have any effect, it is by their action upon it as an incident excitor, 
and not as a motor or muscular nerve. 

3. Organic disease of the cerebrospinal axis. — That it may 
depend on this cause is proved by a case mentioned by Dr. Coley 
(on Infants and Children, BelVs edition, p. 226) who states that 
in a fatal instance which occurred in his own family, the only 
morbid appearance found on dissection was a large exostosis 
growing on the inner surface of the occiput, which compressed the 
cerebellum and produced chronic inflammation of the dura mater. 
No disease was discoverable either in the cervical or thoracic 
glands. Dr. Kyll (Arch. Gen. de Med. t. xiv, 1837, p. 94) 
quotes a case from Dr. Corrigan, of Dublin, which had lasted 
three months, in spite of calomel, emetics, and antispasmodics. 
Attention was called by chance to the spinal column, when it was 
discovered that pressure over the third and fourth cervical ver- 
tebrae was very painful, and produced loud cries from the child. 
Two applications of four leeches, at an interval of two days, to 
that point, removed all the symptoms, and the child recovered 
perfectly. 

Dr. M. Hall (Diseases and Derangements of the Nervous Sys- 
tem, 1841, p. 99) states that the crowing inspiration may arise 
from affections of the centre of the excito-motory system. He 
quotes a case related to him by Mr. Evans, of Hampstead, of 
spina bifida, in which "there was a croup-like convulsion when- 
ever the little patient turned so as to press upon the tumour." He 
states, moreover, that he found induration of the medulla oblongata 
in one case of the disease. 

4. That it is a neurosis. — This is the opinion, according to MM. 
Rilliet and Barthez, of Caspari, Pagenstecher, Roesch, and Hach- 
man. It is that, also, of Rilliet and Barthez, and, as we have 
already seen, of MM. Blache, Herard, and Dr. M. Hall. 



NATURE AND EXCITING CAUSES. 413 

That the disease is, in fact, in the great majority of cases, a 
simple neurosis, is proved, T think, by the opinions just quoted, by 
the autopsies of M. Herard (already referred to), and by a case 
published by M. Constant, and cited by M. Blache (Loc. cit. p. 
584). This was the case of a boy twenty-one months old, who 
was taken to the Children's Hospital of Paris, with well-marked 
symptoms of laryngismus stridulus, and died there some days 
afterwards of small-pox. At the autopsy the larynx and brain 
were found to be healthy. Merriman also relates two cases in 
which the children died in fits, both of which were examined by a 
skilful anatomist, but " not the slightest appearance of cerebral 
affection" could be discovered. 

That it is not always, however, a neurosis, is shown, it seems 
to me, by the cases quoted under the first head from Drs. Hall 
and Coley, and by those in which the disease is accompanied 
from the first by symptoms of inflammation or congestion of the 
brain. 

It has now been shown that the causes of the disease are ex- 
ceedingly variable and uncertain, and that any opinion which asserts 
its dependence on an invariable and constant cause is untenable. 
We must therefore seek some explanation which shall reconcile, 
as far as possible, the facts related above, and harmonize the va- 
rious opinions expressed by the authors quoted. 

It seems to me that the explanation given by Dr. Hall [Loc. cit.), 
is the only one which accounts satisfactorily for the phenomena of 
the disease, and reconciles the contradictory accounts of its nature 
and causes hitherto brought forwards. Dr. Hall regards it as an 
affection of the excito-motory or true spinal system of nerves, pro- 
ducing in mild cases partial closure of the glottis, and difficult in- 
spirations, while in more severe cases the spasmodic disposition 
extends to other parts of the body, to the eyeballs, and to the 
flexors of the fingers and toes. In very violent attacks, the 
glottis is entirely shut, the respiration for a time suspended, and 
from the consequent impediment to the circulation, the nervous 
centres are violently congested, and general convulsions not un- 
frequently produced. 

The causes may be either centric, seated in the nervous centres, 

35* 



414 LARYNGISMUS STRIDULUS. 

or centripetal, in the excitor or incident nerves. In the great ma- 
jority of cases, the causes are centripetal, consisting of various 
morbid conditions situated at the peripheral extremities of the 
nerves, which become causes in consequence of the irritation they 
establish in the nerve-extremities, which is transmitted to the 
spinal centre, and thence reflected through the various efferent 
or motor nerves to the different portions of the muscular apparatus 
affected in the disease, the larynx, face, extremities, and lastly, 
in severe cases, the whole body. The principal causes of this 
class are dental irritation occurring during dentition ; gastric irri- 
tation, arising from excessive or improper food ; intestinal irrita- 
tion arising from constipation, intestinal disorder or catharsis ; and 
perhaps the pressure of enlarged cervical or bronchial glands. 

The centric class of causes includes such as are seated in the 
nervous centres. These are much less common than the former 
class, and give rise to a vastly more dangerous and intractable form of 
the disease. They are different morbid conditions of the brain and 
spinal marrow, as inflammation, congestion, and effusion. That 
such causes sometimes produce the disease is shown by the case 
of exostosis already quoted from Coley ; that of spinal irritation 
from Kyll ; that of Dr. Hall, in which he found induration of the 
medulla oblongata, and the one of spina bifida reported to Dr. Hall 
by Mr. Evans. In the latter case the tumour was seated on the 
loins. Mr. E. proposed to treat it by compression, but on making 
the attempt, found it was followed immediately " by the affection 
described by Dr. J. Clarke" {Hall, Loc. cit. p. 144). Other cen- 
tric causes are passion, vexation, fright, contradiction, etc. etc. 

This theory of the nature of the disease likewise accounts for 
the varying character of the convulsive symptoms. The laryngeal 
spasm, from which the disease derives its name, does not consti- 
tute the whole malady ; it is only one of the symptoms, though 
the principal one, and that by which it is particularly charac- 
terized. The other convulsive phenomena, which generally occur 
only in severe attacks, or after the disease has continued for some 
time, are distortion of the face, strabismus, carpo-pedal spasms, 
and general convulsions. The hydrocephalic symptoms which 
occur towards the termination of some cases, and the serous effu- 
sions within the cranium found after death, are, it ought to be re- 



NATURE SYMPTOMS. 415 

collected, often the consequences of the congestion of the brain 
and asphyxia, which take place during the more or less complete 
closure of the larynx. 

Before proceeding to the description of the symptoms, I wish to 
make a few remarks on the forms of the disease. 

M. Herard (Loc. cit.) makes three forms, one, in which the 
spasm affects chiefly the larynx, to which he applies the term 
laryngeal, another, in which the diaphragm is principally affected, 
which he calls diaphragmatic, and a third, which is a combina- 
tion of the two just named. 

I shall describe but one form, under the title of laryngismus 
stridulus, but after concluding the history of the symptoms of that 
affection, I propose to give a short account of another spasmodic 
disorder of the respiratory apparatus, popularly known in this 
country under the appellation of " holding-breath spells," and con- 
sisting of a sudden and total arrest for a few instants, of the act of 
respiration. This is thought by Herard to depend upon total 
closure of the glottis, and by Dr. Ranking (Rank. Abst. Med. Sc, 
July to January, 1848, p. 165) to occur during expiration, and to 
depend on spasm of the diaphragm. The latter gentleman states 
that he has seen the attacks frequently in two of his own children. 
It seems to me most probable that it depends on sudden spasm 
of all the respiratory muscles, and not of the diaphragm alone. 
My reasons for thinking so are, that the attacks do, as Dr. Rank- 
ing remarks, occur during expiration ; that they are unaccompanied 
by any sound, at the time ; and that when the spasm is over, the 
child instantly makes a full inspiration, unattended with stridulous 
sound, and generally bursts into a loud fit of crying, which would 
scarcely be the case, were there a disposition to spasm of the 
glottis. 

Symptoms; course; duration. — Laryngismus stridulus begins 
suddenly with a paroxysm of difficult respiration. The larynx is 
contracted spasmodically, and either prevents or impedes the 
entrance of air into the lungs. In most cases, the closure of the 
larynx is only partial, and the respiratory movement continues, 
but is accompanied by prolonged and difficult inspirations, which 
give rise to the crowing or stridulous sound, whence the disease 



416 LARYNGISMUS STRIDULUS. 

derives its name. The crowing sound is generally heard several 
times in each paroxysm, owing to the repeated but only partially 
successful attempts at inspiration ; while in very violent cases it 
occurs only at the beginning and end of the accession, the respira- 
tion being entirely suspended in the middle period. At the 
same time the child presents an appearance of great distress. The 
body is thrown forcibly backwards, the eyes are fixed and staring, 
the nostrils dilated, and the whole countenance indicative of great 
anxiety. If the paroxysm continues many seconds, the face be- 
comes bluish, the extremities cold, and the fingers and toes con- 
tracted. After a few seconds, or a minute, or even longer, the 
spasm of the larynx ceases ; a loud, full inspiration takes place ; 
a fit of crying generally follows, and the child either very soon re- 
gains its usual spirits, or if the paroxysm have been very severe, 
seems weak, languid, and drowsy, and returns more slowly to its 
ordinary condition. Between the paroxysms the child may seem 
perfectly well, and without the least disorder of respiration, or it 
will present the signs of the disorder which is the ultimate cause 
of the laryngeal spasm. 

The paroxysms are most apt to occur during sleep, or as the 
child is waking. They occur spontaneously, and are brought on 
by fretting or crying, coughing, fright, contrarieties, deglutition, by 
the sudden application of cold, and other sudden impressions. At 
the commencement of the disease they recur at rare intervals, and 
often attract little notice, but as the case progresses, become more 
frequent, and may amount to twenty or thirty in the day, accord- 
ing to Kerr. They sometimes cease entirely for some weeks, or 
even months, and then recommence. In a case attended by 
myself (reported in the Am. Jour. Med. Sci. April, 1847, p. 287), 
the attacks lasted during eighteen days, occurring sometimes two 
or three times in an hour, and sometimes much less frequently. 
The child then recovered entirely for a period of seven months, 
when the disease returned, and after continuing for five days, 
caused the death of the child in one of the paroxysms. 

If the disease continues to progress, it almost always becomes 
associated with other spasmodic symptoms. The thumbs are 
drawn tightly into the palms of the hands, and the fingers clasped 



SYMPTOMS. 417 

over them, which gives to the backs of the hands, a swelled and 
tumid look. At the same time the toes are strongly flexed under 
the feet, and the insteps look swelled like the backs of the hands. 
Sometimes the hands are bent on the fore-arms, and the fore-arms 
on the arms. There is often distortion of the face. In severe 
cases, or when the disease has continued for a considerable period, 
epileptiform convulsions make their appearance, and generally 
prove fatal. 

The disease is apyretic in a large majority of cases. When 
fever arises it almost always depends on the condition which has 
occasioned the disordered action of the excito-motory system, or 
upon some accidental complication. The pulse during the parox- 
ysm is small, corded, rapid, and sometimes imperceptible. In the 
intervals it is natural or nearly so. 

Death may occur very early in the disease, or after some weeks, 
months, or according to Kyll, years. In a case communicated to 
me by Dr. Wm. Pepper of this city, death occurred in ten hours 
from the commencement. In one quoted by Rilliet and Barthez, 
it took place at the end of three weeks, and in another, of twenty 
months. 

The duration is very uncertain. It generally, however, lasts 
several months. In Dr. Pepper's case, the duration was but ten 
hours. In my own case it lasted eighteen days, then ceased for 
seven months, returned and proved fatal in five days. In another, 
the notes of which were obligingly furnished me by my friend Dr. 
Benedict, and which I shall append to the article, it lasted four 
months and a half, and was followed by perfect recovery. 

Holding-breath spells. — This form of disorder is mentioned, so 
far as I know, only by Rilliet and Barthez (t. ii, p. 255, 256), 
by M. Herard, and by Dr. Ranking. I have met with five well- 
marked cases of the affection, and believe it to be of quite common 
occurrence. It seldom happens that .the physician is consulted in 
regard to it, as those who have charge of children in whom it 
occurs, almost always ascribe it to temper, and think it of but 
little moment. It appears to be the result of a sudden spasm of 
all the respiratory muscles, so that the child ceases for the time to 



418 LARYNGISMUS STRIDULUS. 

breathe, from which circumstance no doubt, it has received its 
name of holding-breath spell. There is no stridulous sound, nor 
hoarseness of the cry, nor indeed sound of any kind. The face 
is contracted and bluish, the limbs violently agitated at first, and 
then stiff, and after a few seconds, or perhaps a minute in severe 
cases, the spasm yields, and is followed by loud crying, which 
lasts for a few moments, after which the child seems perfectly 
well. The attacks recur with variable frequency ; there may be 
several in a day, or but one, or they may occur only at intervals 
of several days. The most frequent cause of the paroxysms is 
contradiction. They are determined also by fright, pain, and 
crying. They never occur spontaneously, and never during sleep, 
so far as I know. It is to be distinguished from laryngismus stri- 
dulus by the absence of the crowing sound, by its not occurring 
spontaneously or during sleep, and by the absence of carpo- 
pedal or other spasmodic symptoms. It is, I believe, a spasmodic 
affection of respiration, analogous to, though not. exactly similar 
to laryngismus stridulus. 1 have never met with it except during 
the period of the first dentition, and always in children of nervous 
temperament. The five cases that I have met with all recovered, and 
in one only did the life of the child seem to be at all endangered. 
In this instance the paroxysms had recurred very frequently for 
eleven months, and on two occasions were terminated by slight 
spasmodic movements of the limbs, lasting only for a few instants, 
and unaccompanied by insensibility or other dangerous symptoms. 
After these attacks the child was removed to the country, where 
he recovered perfectly. 

Diagnosis. — The only disease with which laryngismus stridulus 
is likely to be confounded is spasmodic laryngitis, or false croup. 
From this it may readily be distinguished by the absence of catarrhal 
symptoms, or fever; by the fact that the paroxysms occur indiffe- 
rently day or night, and that they are much more frequent ; by 
the absence of cough or hoarseness of the voice, even during the 
height of the paroxysm ; by the occurrence of tonic muscular 
spasms, and convulsions; and finally by the chronic course of 
the malady : the converse of all of which symptoms exists in 
spasmodic croup. 



PROGNOSIS TREATMENT. 419 

Prognosis. — The prognosis of the disease is always serious, 
since even the mildest cases may terminate fatally at any moment 
in one of the paroxysms. It is, however, far from being so dange- 
rous a disease as has been supposed by some writers, and amongst 
others M. Valleix, who states that it is almost always fatal. 
(Guide du Med. Prat. t. i, p. 564.) Of 56 cases collected from 
Pagenstecher, Hachman, Ley, Kopp, Hall, Constant, Rilliet and 
Barthez, Kyll, and 4 from my own observation, making 60 in all, 
4 died of intercurrent or consecutive diseases, while of the remain- 
ing 56, 31 were cured, and 25 died of the malady itself. 

The prognosis given by the physician ought to depend in great 
measure upon the cause of the malady. If it depend on dentition, 
improper diet, or gastro-intestinal disease, the case will in all pro- 
bability terminate favourably if a proper treatment be directed 
against those morbid conditions; while if it occur under the in- 
fluence of a centric cause, or of enlargement of the cervical or 
bronchial ganglions, the prognosis becomes much more unpro- 
mising. 

Treatment. — If the views taken of the nature of the disease in 
the above remarks be correct, it must be evident that for the treat- 
ment to offer any considerable chance of success, it must be di- 
rected not merely to the removal of the spasm of the larynx, 
which is only a symptom and not the whole disease, but to the 
remedying of the deeper-seated cause of the disordered functional 
action of the excito-motory system of nerves. 

When dentition is ascertained to be the cause of the attack, 
the gums ought to be carefully watched, and freely scarified, so 
soon as there is the least heat or swelling over the advancing teeth. 
Dr. Marshall Hall deems the use of the gum-lancet one of the most 
important means of treatment that we are possessed of, and recom- 
mends that the gums should be fully divided, " not once, or occa- 
sionally, but twice, or even thrice, daily." In another place, he 
says : " We should lance the gums freely and deeply, over a great 
part of their extent, daily, or even twice a day, and apply a 
sponge with warm water, so as to encourage the flow of blood." 
He even recommends that in very urgent cases, the lateral as well 
as the more prominent portion of the gum, should be scarified. I 



420 LARYNGISMUS STRIDULUS. 

would, however, call the attention of the reader to the circumstance, 
that when the operation of lancing the gum is performed while the 
tooth is still soft and enclosed in its sac, it is apt to be injured 
should it be touched by the lancet, so that it makes its appearance 
at last with a defect which causes an early and rapid decay. This, 
to be sure, is no argument against an operation which may save 
the life of the child, but it should lead us, it seems to me, not to 
cut deeper into the gum than is absolutely necessary, and to avoid, 
if possible, the germ of the tooth, while still in a pulpy state. 

When the disease depends on gastric irritation, the result of an 
unhealthy milk, or of artificial diet, our attention must be directed 
principally to the removal of those conditions. A wet-nurse ought 
to be procured at once if one can be obtained, and the child will 
nurse. If this cannot be done, the diet must be carefully regulated 
by the physician. Ass's milk or goat's milk ought to be used if 
they can be procured ; if not, I would recommend the gelatine diet 
prepared as recommended at page 193. The proportion of the 
ingredients must be regulated by the condition of the stomach. If 
the digestive power be very weak, the proportion of milk must be 
only a fourth or even a sixth for a few days, while the amount of 
cream must bear its usual ratio to the milk. 

When the child is thin and pale, and the stomach evidently 
weak and dyspeptic, it is well to resort to small quantities of stimu- 
lants, and to tonics in proper doses. The best stimulant is fine old 
brandy, of which from five to ten drops may be given three or four 
times a day, or every two or three hours. Or we may administer 
the aromatic spirits of hartshorn in connexion with, or without 
the brandy ; of this about ten or fifteen drops should be given four or 
five times a day, or alternately with the brandy. Of tonics the 
most suitable, it seems to me, are quinine, in the dose of a quarter 
of a grain three or four times a day, or the citrate of iron and qui- 
nine, in the dose of half a grain, given in the same way. Another 
very excellent stimulant and tonic is the Huxham's tincture of 
bark ; of which about five drops may be prescribed in the place of 
brandy. This kind of treatment will scarcely fail to stimulate the 
digestive power of the stomach to greater activity after a few days, 



TREATMENT. 421 

and of course to improve the nutritive function and strength of the 
patient. 

When the disease appears to depend on intestinal irritation, we 
must inquire carefully into its nature and causes. It may be con- 
nected with constipation, diarrhoea, or on an unhealthy state of the 
contents of the bowels. It is often dependent on the presence of 
crude or imperfectly digested food in the digestive tube, and when 
this is the case, the only proper method of treatment is to attend 
to the stomach and to discover and employ some diet that can be 
digested. The stools are often found to be very offensive, light- 
coloured, and pasty, conditions generally resulting from imperfect 
action of the liver. Under these circumstances small doses of 
mercurials should be resorted to in combination with or followed 
by mild aperients, as castor oil or rhubarb. When diarrhoea is 
present, it must be treated according to its causes, as recommended 
in the articles on simple diarrhoea and entero-colitis. When, on 
the contrary, constipation appears to be the cause of the disorder, 
it is to be treated by regulation of the diet, by the daily use of 
warm water enemata, (particularly recommended by Dr. M. Hall,) 
or, if these do not answer, by the exhibition of small doses of the 
mildest aperients. 

Dr. Hall states that by strict attention to dentition, and to gastric 
and intestinal irritation in the dawn of the disease, he has suc- 
ceeded in curing all the cases he has seen but one, and in that he 
found induration of the medulla oblongata. 

By those who suppose the disease to depend on enlargement of 
the thymic, cervical, or bronchial glands, it has been proposed to 
endeavour to procure a reduction of the hypertrophy, by frequent 
applications of leeches, and by the use of exutories upon the thorax, 
by the employment of strong purgative medicines, and by the ad- 
ministration of mercury, digitalis, and iodine. In a case apparently 
connected with enlargement of the bronchial or cervical glands, I 
would prefer to direct my treatment to the invigoration of the gene- 
ral health by attention to diet, to the use of tonics, and by proper 
exposure to fresh air, whilst I would employ internally, anti- 
spasmodics and the preparations of iodine. 

36 



422 LARYNGISMUS STKIDULU9. 

When the disease depends on a centric cause, that must be 
treated, if it can be detected, according to its nature. 

Antispasmodics. — Whatever be the causes of laryngismus stri- 
dulus, it is undoubtedly proper, whilst our chief efforts are directed 
towards their removal or mitigation, to make use of antispasmodics 
in order to moderate the spasmodic symptoms which are the ex- 
pressions of those causes. The remedies of this class most highly 
recommended are cherry-laurel water, musk, assafoetida, oxide of 
zinc, and small doses of ipecacuanha. The most efficient are pro- 
bably the oxide of zinc, which is recommended by M. Brachet, 
( Traite Pratique des Convulsions dans FEn/ance,) as one of the 
best antispasmodics that can be used in the convulsions of children, 
the fluid extract of valerian, and aromatic spirits of hartshorn. M. 
Brachet always combines the oxide of zinc with extract of hyoscya- 
mus, and gives at least two grains of the former with four of the latter, 
in divided doses, in the twenty-four hours. He states that he has 
never given more than ten grains of each in the period mentioned. 
Of the fluid extract of valerian, about a teaspoonful, or even more, 
might be given in twenty-four hours, to a child one or two years 
old. It should be mixed with water, of course. The aromatic 
spirits of hartshorn may be given as recommended above. 

It must never be forgotten, however, that remedies of this class 
are to be employed only as palliatives and adjuvants, and not as 
curative agents. 

Treatment during the paroxysm. — When the child is attacked 
with one of the paroxysms of difficult breathing, it should be lifted 
at once into a sitting posture, if it be reclining, and fanned, or car- 
ried to an open window, if the weather be not too cold. At the 
same time, a little cold water should be sprinkled upon the face, and 
if the attack be violent, we may resort to what is recommended by 
Dr. Hugh Ley, and Dr. Hall, tickling of the fauces to produce 
nausea or vomiting, or irritation of the nostrils with a feather, so as 
to occasion gasping respiration. In a case which occurred to my 
father, Dr. C. D. Meigs, accompanied with severe general convul- 
sions, he found that the suspension of the respiration could very 
generally be broken in upon, and the paroxysm sometimes averted, 



TREATMENT CASE. 423 

by the application of a piece of ice, wrapped in a cloth, to the 
epigastrium and lower part of the sternum. 

To prevent congestion of the brain and effusion, which some- 
times take place as the effects of the attacks, Dr. Hall recom- 
mends a kw leeches or cups to the head, the application of an 
alcoholic lotion over the whole head, or the use of the ice-cap. At 
the same time the bowels ought to be speedily moved by large 
enemata, either of simple water, or of water containing salt. 

Removal to the country. — When the disease persists, in spite of 
the means above recommended, and especially when it depends on 
dentition or digestive irritation, change of air will often produce a 
wonderful effect, and should always be tried. The good effects of 
removal from the city to the country are strikingly shown in the 
case communicated to me by Dr. Benedict. 

Case communicated by Dr. Pepper. 

" A boy aged four months, remarkably healthy and well-deve- 
loped, after suffering a few days with slight catarrhal symptoms, 
was suddenly seized with a peculiar stridulous crowing respiration. 

" I saw the child about half an hour from the commencement of 
the attack, and found it with a pulse of 140, pale face, and livid 
lips. The pupils were contracted and the hands firmly clinched ; 
the crowing sound was very loud, and attended every act of inspi- 
ration. At times the respiration and circulation would be entirely 
suspended for many seconds, followed by great lividity of the sur- 
face, and coldness of the extremities. 

" Eight or ten leeches were applied behind the ears, the feet 
placed in warm water, and a dose of 01. ricin. administered, to be 
followed by saline enemata. 

"Four hours from the commencement of the attack, all the 
symptoms were greatly aggravated ; the wrists and fingers were 
firmly flexed, these spasms coinciding with the arrest of the circu- 
lation and respiration ; there was now perfect insensibility. The 
child was placed in a warm bath, cold was applied to the head, 
and a sinapism along the spine, without, however, affording any 
relief to the crowing inspiration, or other spasmodic symptoms. 



424 LARYNGISMUS STRIDULUS. 

" At the suggestion of Dr. C. D. Meigs, the child was now 
placed on its right side, with the shoulders elevated ; this position 
to be maintained at least six hours. At the end of that time the 
child was in no respect improved, and accordingly, at the sugges- 
tion of Dr. M., six leeches were applied over the cardiac region ; 
3i of lac assafoetid. was thrown into the rectum, and a blister ap- 
plied to the back of the neck. 

" The child expired at midnight, about ten hours from the com- 
mencement of the attack, the crowing respiration, with more or 
less asphyxia, having persisted throughout. 

" Autopsy thirty-six hours after death. — Mucous membrane of 
larynx injected, but in other respects natural. Thymus gland 3J 
inches long, 2 J wide, and at its upper part f of an inch thick. 
Weight, 620 grains, or ten drachms and one scruple. Lower 
lobes of both lungs greatly congested. Heart natural. The brain 
unfortunately could not be examined." 

Remarhs. — It seems to me that the above case was clearly one 
of laryngismus stridulus, dependent upon a centric cause, probably 
congestion of the cerebellum or medulla oblongata. It was, in 
fact, a case of what is called by M. Valleix " eclampsia with suffo- 
cation." Nevertheless, violent general convulsions, attended with 
crowing respiration from the first, are very rare ; and the above 
case is curious as an instance of that kind. I would particularly 
call the attention of the reader to the marked signs of asphyxia 
that were present, which condition, in all probability, conduced 
very much to the rapidly fatal termination. 

Case communicated by Dr. Benedict. 

"The subject of this case was a boy born in July, 1845. He 
was a large, hearty child, and remained well until January, 1846, 
when his mother's milk failed, and he was placed upon artificial 
diet. From this time to May following, his diet was cream and 
water, barley water, oatmeal, arrow-root, pounded crackers boiled 
with water, and gum water, all of which were tried in turn, being 
prepared and administered with the greatest caution, as to time 



case. 425 

and quantity. A wet-nurse was tried, but the child refused the 
breast entirely. 

" On the 27th January, he was attacked with diarrhoea which 
lasted one week. This was followed by constipation, the stools 
being white, firm, tenacious, and offensive. The constipation con- 
tinued up to July, when it was replaced by diarrhoea. 

" February 4th, 1846. — On this day, the child being seven 
months old, was first observed a spasm of the larynx, producing a 
shrill, croupal whistle, or ooh, ooh, during two or three successive 
respirations, and followed by a cessation of breathing for some 
seconds, long enough to dash water in his face, carry him to the 
window, pat him on the back, etc. These spells occurred during 
the sleeping and waking state, and especially during crying or 
laughing, and continued almost daily and often many times a day 
and night until June, when he was taken into the country. 

" Simultaneously with the laryngeal spasm, appeared contractions 
of the upper extremities, the thumbs being drawn tightly into the 
palms of the hands, the fingers flexed over the thumbs, and the 
hands bent on the fore-arms. The backs of the hands were swol- 
len, and the skin looked tight and polished. 

" For a few days in the middle of February there was a subsi- 
dence of all the symptoms, with decided improvement in every 
respect. 

" On the 25th of the same month, occurred a return of all the 
symptoms, with extension of the spasm to the feet, the toes being 
bent under the feet, the insteps much swelled and having a polished 
appearance. At the same time there were occasional spasmodic 
movements of the muscles of the face, arms, and body, resembling 
those of chorea. This condition continued with occasional relaxa- 
tions up to the 11th of June. 

" The stomach was exceedingly delicate, rejecting the most 
carefully selected nourishment, and at times refusing all food. 
The child became pale, thin, and timid, was disturbed by the 
slightest noise, and shunned the light as painful. 

"He was removed to the country on the 11th of June. There 
his health was gradually restored. The appetite improved, the 
spasm of the larynx and contractions of the extremities gradually 

36* 



426 LARYNGISMUS STRIDULUS. 

relaxed, and the thumbs were at last liberated, the skin under 
them having taken on the appearance of mucous membrane. 
There was no return of the disease after the middle of June, 
although the child had a severe attack of diarrhoea in July, after 
which he got perfectly well, and has remained so up to the present 
time (June, 1847). The first tooth made its appearance in Sep- 
tember, and he now has fourteen, and has cut them all without 
the least accident. During the last eight months he has been re- 
markably fat and hearty. 

" I am not aware that any medicine had any effect in removing 
the disease. Calomel in large and small doses, antispasmodics of 
all kinds, frictions over the spine, blisters to the back of the head, 
alteratives, laxatives, etc., were persevered in without benefit. On 
removing him to the country, and feeding him on milk warm from 
the cow, at first diluted, and afterwards pure, an improvement was 
speedily observed." 

Dr. B. adds: " There cannot, I think, be any doubt that the 
disease originated in the stomach, and extended to the bowels, 
perhaps the liver, and to the nervous system." 

Remarks. — The above case was evidently one of laryngismus 
stridulus, as that disease is described by different medical writers. 
It must be clear to every one, I think, that the cause was seated as 
Dr. Benedict remarks in the digestive apparatus. The history of 
the case, the onset of the disease soon after the child was put upon 
artificial diet, the difficulty of finding food to agree well, the con- 
dition of the bowels, the offensive, bileless stools, the persistence of 
the case so long as the stomach continued feeble and the food im- 
proper, and the rapid improvement after the child had felt the 
tonifying influence of the country air, all seem to me to show con- 
clusively that the difficulty was in fact disordered digestion. 

I would recommend those who wish to observe still farther the 
influence of disordered digestion in the production of nervous dis- 
ease, to peruse three cases detailed by Dr. Coley (Bract. Treatise 
on the Bis. of Children, Bell's edition, pages 233, 234, 235.) 



case. 427 



Case observed by the author. 

The following case is the only one I have met with myself. I 
extract the following account of it from a paper on croup. (Am. 
Journ. Med. Sci. April, 1847.) 

The patient was a girl, five months of age. I saw the child 
first on the 28th of March, 1844. The first attack occurred the 
day before I was called, but as the mother supposed it to be a 
matter of but little consequence, she did not send for me until the 
next day. The child was well grown, and except a rather too great 
paleness, looked strong and healthy. It was playful and good- 
humoured, nursed freely, had no fever, and between the parox- 
ysms presented the appearances of perfect health. The paroxysms 
occurred frequently in the course of the day and night, sometimes 
two or three times in an hour, or not so often. They often waked 
the little thing suddenly from tranquil sleep. The accession con- 
sisted of a succession of long and difficult inspirations, accom- 
panied by a peculiar whistling or crowing sound, such as might 
be supposed to depend on the passage of air through a narrow 
aperture. During the attack, the face assumed an expression of 
great anxiety ; the respiratory muscles contracted with violence, 
and there seemed to be for the time imminent danger of suffoca- 
tion. After several seconds or a minute, the shrillness of the 
sound diminished, the struggling subsided, and soon the respira- 
tion became perfectly natural, and the child seemed well. The 
paroxysms were usually followed by fits of crying, which, how- 
ever, were easily pacified. 

The paroxysms gradually diminished in frequency and violence, 
and ceased entirely after the 13th of April. The treatment con- 
sisted simply in careful attention to the general health, and in the 
frequent use of warm baths and mild nauseants. 

The child remained perfectly well, with the exception of a slight 
attack of cholera infantum, until the following November, seven 
months after, when the disorder recurred. Several paroxysms 
occurred between the 12th and 17th of the month, but as (hey 
were slight and unattended by other symptoms of illness, the 



428 CONTRACTION WITH RIGIDITY. 

mother was not alarmed, and paid but little attention to them. On 
the 17th of the same month, the child was sitting on the floor 
amusing itself with some playthings. There were no persons in 
the room except young children. They saw the little thing stoop 
forward suddenly, as though in play, and therefore did not regard 
it immediately. As it remained in that position, however, they 
went to it, took it up, and found it was dead. It had perished 
suddenly, no doubt in one of the paroxysms of crowing. 

An autopsy was made, in which the larynx and thoracic 
organs were examined, but nothing was found to explain the cause 
of the disease or the sudden death. 



ARTICLE III. 

CONTRACTION WITH RIGIDITY. 

This is the disease called by the French contracture, I shall 
treat of it as idiopathic contraction with rigidity. It has been 
little known until within a few years, and yet is clearly not a 
very rare affection in Paris, from the number of cases on record 
in different medical journals and works. I have never met with 
an instance myself in this country. The case of laryngismus 
stridulus communicated to me by Dr. Benedict, and appended to 
the article on that disease, furnishes a very good example of con- 
traction co-existing with the former affection. 

The disease is evidently one of the forms of eclampsia, which 
assumes such a variety of shapes during infancy and childhood. 
Though it generally exists as an idiopathic and distinct malady, 
it is in other cases associated with, or follows laryngismus stri- 
dulus or spasm of the glottis, and in others again, is combined 
with attacks of general convulsions. 

Definition. — By idiopathic contraction with rigidity {contracture 
of the French writers), is meant the involuntary tonic contraction 
of different flexor muscles of the extremities, particularly those of 
the fingers and toes, but sometimes of the fore-arms and arms 
also, existing independently of organic disease of the cerebro-spinal 



CAUSES NATURE. 429 

axis. It has been described by different English writers in con- 
nexion with laryngismus stridulus, under the title of " carpo-pedal 
spasms," " cerebral spasmodic croup," " croup-like convulsions," 
etc., etc. I believe, however, that it will be useful to describe it 
separately from that disorder, for though of the same nature, and 
sometimes associated with it, it often exists independently of such 
complication. 

Causes. — It is most common between the ages of one and three 
years. It is much oftener sympathetic than essential, and its 
most frequent causes are difficult dentition, various diseases of the 
digestive tube, pneumonia, bronchitis, masturbation, and un- 
favourable hygienic conditions. In some few cases, the disease is 
truly essential, since no pathological cause whatever can be de- 
tected. It is merely necessary to say that it is often symptomatic 
of disease of the brain, but of that form of the affection nothing 
will be said in the present article. 

Nature of the disease. — It appears to consist of a functional de- 
rangement of the true spinal system, occurring without any cause 
that can be detected ; or determined by the existence of some irri- 
tation affecting incident excitor nerves. I once saw a child two 
years of age, who, after a restless, uneasy night, presented in the 
morning tonic contraction of the flexors of all the toes of both 
feet, so that the insteps were swelled, and looked smooth and 
polished. There was no other sign of sickness except peevishness. 
Learning on inquiry that the bowels had been somewhat con- 
stipated for several days, and that the materials of the scanty 
stools which had been discharged, were dark-coloured and very 
offensive, I ordered a dose of castor oil containing two grains of 
calomel. The contraction continued unyielding until six o'clock 
in the afternoon, when a very copious, dark-coloured, viscid and 
offensive stool occurred, and the contraction immediately ceased. 
Here the cause of the contraction was evidently an accumulation 
of unhealthy fecal matter in the intestine, which, irritating certain 
sensitive cords of the cxcito-motory system, caused a reflex motor 
action that gave rise to permanent muscular contractions. In 
other cases the disturbance of the excito-motory system depends 
on the irritation of excitor nerves occasioned by the process of 



430 CONTRACTION WITH RIGIDITY. 

dentition, by indigestion, by diarrhoea, pneumonia, pleurisy, etc. 
In other instances, again, to which the term essential must be ap- 
plied, it seems to depend simply on general debility and anemia, 
which are well known to be productive of functional disease of the 
nervous system. 

Symptoms ; course; duration. — The disease rarely attacks chil- 
dren previously in good health, but generally those already suffering 
from some disorder of the general health, or a severe local affection. 
When sympathetic, the first symptom noted is the contraction 
which constitutes the disease. When essential, on the contrary, 
the onset is sometimes marked by various nervous symptoms, such 
as giddiness, headache, or somnolence, which soon pass off, leav- 
ing the simple contraction with rigidity as the only disease. In 
most cases, however, the attack begins with the muscular contrac- 
tion, which generally affects the superior extremities first, and 
gradually extends to the inferior. 

When the disease is fully developed, the thumbs are drawn 
down into the palms of the hands, and the fingers, strongly flexed 
at the metacarpo-phalangeal articulations, cover and conceal the 
thumbs. At the same time that the metacarpo-phalangeal articu- 
lations are flexed, the phalanges themselves remain extended and 
the fingers are separated from each other. The contraction gene- 
rally affects the wrist-joints also, so that the hands are strongly 
flexed upon the fore-arms, and in some rare cases the latter 
upon the arms. The disorder usually affects the inferior extre- 
mities also, the toes being in a state of tonic flexion or extension, 
the foot rigidly extended upon the leg, and its point sometimes 
drawn inwards. The spasm very rarely extends to the knees. 

Children old enough to describe their sensations generally com- 
plain of stiffness in the affected parts, with more or less severe 
pains darting along the course of the nerves. The contracted 
muscles are hard and rigid to the touch, and sometimes enlarged 
so as to appear in strong relief under the skin at all ages. In 
slight cases the contractions can be overcome by very moderate 
force and without pain, whilst in those which are more severe, the 
attempt is difficult and productive of acute pain in the rigid parts. 
The backs of the hands and insteps present a swollen appearance, 



SYMPTOMS — DIAGNOSIS. 431 

and the skin over these points is smooth and polished. In the case 
communicated by Dr. Benedict, appended to the article on laryn- 
gismus stridulus, the skin under the thumbs had assumed the ap- 
pearances of mucous membrane, from the long and close confine- 
ment of the member. 

In addition to the symptoms already enumerated, which are 
characteristic of the malady, there are others which require atten- 
tion. The child is of course unable to walk or perform any pre- 
hensile movement. The intelligence and senses always remain 
perfect in simple, uncomplicated cases. The nervous system shows 
signs of disorder in the form of restlessness or languor, and irrita- 
bility, with crying and peevishness. In the great majority of in- 
stances, these are the only nervous symptoms, though in some 
there are general or partial convulsions, strabismus, and diminution 
of sensibility. Of these the most frequent is convulsions, which 
generally come on a few days after the attack, or precede the fatal 
termination. In the case of Dr. Benedict, referred to above, there 
were occasional choreatic movements of the face, arms, and body. 
The simple disease is unaccompanied by any febrile movement, 
and the organic functions go on naturally. In the sympathetic 
form, on the contrary, there are the various symptoms of the 
disease which acts as the cause of the contraction, whether that be 
abdominal or thoracic. The most common train of symptoms, 
in young children, is probably, that which accompanies gastric or 
intestinal derangement, dentition, etc. The course and duration 
of the disease are very irregular and uncertain. When once 
developed it may last from weeks to months, either slowly in- 
creasing in severity, or remaining stationary for a length of time. 
As a general rule, after it has lasted for some time, it becomes in- 
termittent, sometimes diminishing or even disappearing entirely 
for a period, then reappearing or increasing, to subside or cease 
again, and so changing without regularity or evident cause, until 
at last recovery gradually takes place, or death occurs from the 
concomitant disease, or in a paroxysm of convulsions. 

Diagnosis. — The only difficulty in the diagnosis of idiopathic 
contraction is to distinguish it from symptomatic contraction, or 
that which depends upon cerebral or spinal disease. The kinds of 



432 CONTRACTION WITH RIGIDITY. 

cerebral disease which most frequently occasion contraction are 
tubercle of the brain, and meningeal hemorrhage. The distinction 
can generally be made with considerable facility, however, by atten- 
tion to the various disorders of intelligence and sensibility, to the 
fever, constipation, vomiting, and different modes of invasion and 
progress which characterize the symptomatic form. The following 
table, taken from Rilliet and Barthez, will assist in the diagnosis. 

Symptomatic Contraction. Essential Contraction. 

Cerebral symptoms, special func Similar cerebral symptoms, but only 
tional disorders, (convulsions, strabis- in exceptional cases, sometimes ac- 
mus, dilatation of the pupils, etc.,) pre- companying, but never scarcely pre- 
ceding or accompanying the contrac- ceding the contraction, 
tion. 

In many cases irregularity of the No irregularity of the pulse, 
pulse. 

Generally partial, and commencing Binary, commencing in the fingers 

usually in the elbows and knees, and and toes, 
in a single extremity. 

Almost always permanent. Remarkably intermittent. 

Prognosis. — The prognosis must depend on the cause of the 
malady. The contraction itself has no influence whatever on the 
termination. The fatal termination has always resulted from the 
anterior or concomitant disease. Six cases observed by M. Bar- 
rier all recovered. The case communicated to me by Dr. Bene- 
dict, in connexion with laryngismus stridulus, also terminated 
favourably. The prognosis is favourable, therefore, when the 
attack occurs in a child of naturally good constitution, and when 
the cause of the disease is not a permanent or incurable one. The 
possibility of the occurrence of fatal convulsions should always lead 
us to make a guarded prognosis. 

Treatment. — The treatment must depend on the circumstances 
under which the disease has made its appearance. When it occurs 
in the course of an acute local affection, the treatment must of 
course be that which is proper for the concomitant disorder. When 
it depends on dentition, or on gastric or intestinal derangement in- 
duced by improper diet, the treatment is the same precisely as 



TREATMENT. 433 

that recommended for laryngismus stridulus dependent on the 
same causes. 

It may be stated that, as a general rule, all violent remedies, as 
bleeding, calomel except in very minute doses as an alterative, 
drastic cathartics, and blisters, can scarcely fail to be injurious, 
unless manifestly necessary in the treatment of the concomitant 
affection. 

It is proper in almost all cases to combine with the treatment 
already recommended, the employment of antispasmodic remedies, 
particularly when the contractions persist after the removal of the 
primary disease. 

The best remedies of this class are the warm bath, used every 
day ; orange-flower water ; the fluid extract of valerian ; assafce- 
tida, and camphor. The diet ought generally to be nutritious and 
strengthening, particularly when the patient is weak and delicate. 

In conclusion, I may state that the treatment should be very 
much the same as that proposed for laryngismus stridulus, and I 
therefore refer the reader to that subject for more detailed informa- 
tion. 



ARTICLE IV. 

CHOREA. 

Definition ; synonymes ; frequency. — Chorea is a non-febrile, 
convulsive disease, characterized by irregular and imperfectly 
co-ordinated, but not completely involuntary, contractions of 
different parts of the muscular system, and particularly of the 
extremities. 

It is called also St. Vitus's dance, chorea sancti viti, choreo- 
mania, epilepsia saltatoria, and by various other titles. 

Without being very rare, chorea is certainly not of very frequent 
occurrence. M. Rufz states that of 32,976 children admitted into 
the Children's Hospital of Paris in ten years, only 189 were 
affected with chorea, or 1 in 377. (Diet, de Med. t. vii, p. 544.) 
I have met with but four cases in private practice in the course of 
several years' experience. 

37 



434 CHOREA. 

Predisposing causes. — Age. — Chorea very rarely, some writers 
say never, occurs during infancy. M. Constant, however, reports 
a case at four months of age. According to M. Ruiz, it is seldom 
met with between one and six years of age, since of 189 cases, 
in only 10 did it occur within that period ; while between six and 
ten years of age it is much more common (61 in 189 cases) ; 
and between ten and fifteen years still more so (118 in 189). It 
is therefore much the most frequent about the period of puberty. 

Sex. — It is much more frequent in girls than boys. This is the 
experience of all writers. 

Constitution does not seem to exert much influence in its pro- 
duction, though it is generally thought to be most apt to occur in 
children of delicate, excitable, and nervous temperament. The 
belief in hereditary predisposition seems to be unfounded. The 
disease appears to commence more frequently in summer than in 
winter, and yet it is scarcely known in tropical climates. 

Exciting causes. — Of many exciting causes that have been 
mentioned by different writers, the one which seems most frequent 
and most clearly established, is the influence of terror. Besides 
this are cited imitation, blows and falls upon the head, fits of vio- 
lent anger, contrarieties, masturbation, the difficult establishment 
of the menstrual function in girls, or suppression of that function, 
and the sudden drying up of ulcers or eruptions. Various diseases 
have been thought to occasion chorea, particularly those of the 
gastro-intestinal tube. 

Anatomical lesions. — It seems well established by the researches 
of many different observers that there is no characteristic anato- 
mical alteration in chorea, since in a large majority of the cases 
examined after death, no lesion of the cerebro-spinal axis can be 
detected. In some few instances, however, lesions of these organs 
have been met with, the most frequent of which are inflammation 
of the tubercula quadrigemina, serous effusions, hypertrophy of 
the cortical substance of the brain, induration or softening of the 
spinal marrow, and other lesions. From these circumstances, the 
disease has been divided, like convulsions, into idiopathic and 
symptomatic. 

Symptoms ; course ; duration. — The disease may be general 



SYMPTOMS. 435 

or partial ; in the first case it affects all the limbs, the face, and 
some of the muscles of the trunk : in the second it implicates 
only one side, the upper extremities, or a single member. It 
has been asserted that often only one side was affected, and that 
in most of the cases it was the left. This is denied, however, by 
Riliiet and Barthez, who state that they have met with but a single 
instance in which it was confined to one side throughout the attack. 
Of four cases that I have seen, it was general in three, and con- 
fined entirely to the right side in one. I shall describe first the 
prodromes of the disease, then the invasion, and afterwards the 
symptoms as they exist in fully developed cases. 

Pi'odromic symptoms. — It is doubtful whether there are, as a 
general rule, any well-marked prodromic symptoms. The only 
ones that have been mentioned with any authority are irritability 
and peevishness of temper, an unusual degree of impressibility, 
languor, debility, disturbance of the organic functions, exhibited 
by deranged appetite and an irregular state of the bowels, and 
after a time a certain quickness and irregularity of the movements, 
which mark the commencement of the characteristic symptoms of 
the malady. 

Invasion. — The onset of the disease is, as already stated, either 
sudden or gradual, so that it may be several days or longer in 
reaching any considerable degree of severity, or it may, par- 
ticularly when the cause has been of a sudden and energetic 
nature, reach its height in a few hours. In most cases, however, 
it begins with some unusual and singular movements in one of the 
upper extremities, and as a general rule in the left. The choreatic 
movements are often observed first in the fingers, and at the 
same time, or soon after, in the face. Sooner or later they in- 
crease in severity, and extend to the other arm, to the legs and to 
the tongue, and the disease is fully developed. 

Symjrtoms of confirmed general chorea. — At this stage the move- 
ments are exceedingly diversified and irregular. The limbs arc agi- 
tated by involuntary contractions of the muscles into every attitude 
possible for them to assume. The fingers are opened and shut, 
brought together or separated without any regularity. The hands 
are flexed and extended upon the fore-arms, or pronated and 



436 CHOREA. 

supinated, whilst the fore-arms are flexed or extended upon the 
arms, and the arms moved at the shoulders into every imaginable 
position. Such are the irregularity and rapidity of the movements 
that it is often with great difficulty that the patient can seize any- 
thing with the hands, and when once the object is attained, the 
child frequently cannot do with it what it wishes. This imperfect 
control over the movements of the hands and arms sometimes 
prevents the patient from carrying its food and drink to the mouth, 
excepting with the utmost difficulty, and may make it necessary to 
feed the child. 

The inferior extremities are affected with movements similar to 
those of the arms. Walking is always more or less difficult, and 
in some severe cases impracticable. The patient totters from 
side to side, or walks rapidly a short distance, and then suddenly 
stops. Sometimes the progression is accomplished in a zigzag 
direction, and at others by fits and starts as it were, whilst in 
others again, the walk is rapid and sudden, almost a run. The 
child often falls while walking or running, either from meeting a 
slight obstacle, or in consequence of the irregular and imperfect 
muscular action. In some instances standing is impossible, the 
knees bending suddenly under the weight of the body. It was no 
doubt the peculiar, irregular and dancing movements of the inferior 
extremities during the attempts to walk and stand, that gave to the 
disease its original name of St. Vitus's dance. 

The convulsive movements of the face and head are not less 
singular than those of the limbs. The face is distorted into all 
kinds of expressions, so that it assumes by turns that of the most 
opposite emotions : sadness, terror, joy, or grief. The mouth is 
opened and shut, or its corners drawn apart with the greatest 
irregularity ; the tongue is occasionally protruded between the teeth, 
and sometimes moved rapidly in the mouth, so as to cause a 
clacking sound ; the lower jaw is depressed and elevated, or moved 
in a lateral direction, and with such violence perhaps as to in- 
jure the tongue or teeth. In consequence of the irregular motions 
of the tongue and mouth, articulation becomes difficult, and the 
child either stutters or speaks slowly and badly, or can pronounce 
only monosyllables. Whilst the face and limbs are thus contorted, 



SYMPTOMS COURSE. 437 

the head is moved rapidly from side to side, or backwards and 
forwards, or undergoes constant rotation. In severe cases the 
choreatic movements affect the trunk also, so that the patient 
cannot lie upon a bed, but rolls and twists about the floor with 
such violence as to bruise and excoriate the skin. Deglutition is 
sometimes slightly embarrassed, and the child is obliged to swallow 
with great rapidity ; in some few cases a peculiar loud cry, 
like that which occurs in hysteria, dependent apparently upon 
a spasm of the larynx, has also been observed. The organic 
muscular apparatus is probably never affected with true choreatic 
spasms. 

The disease is unaccompanied by pain unless it be attended with 
some complication, and what is very singular and remarkable, the 
constant and often very violent muscular contractions do not seem 
to occasion fatigue. 

The general symptoms require some attention. The choreatic 
movements are almost always increased by emotion, as terror, 
anger, contrarieties, and by the consciousness of being observed. 
Sleep generally suspends them entirely. In very bad cases they 
are said to produce insomnia, or to wake the child frequently in the 
night. The intelligence is rarely affected, except in very severe 
and long-continued attacks. The temper is often irritable and 
capricious. General and special sensibility commonly remain 
natural. In simple, uncomplicated attacks, the pulse, as a rule, 
remains natural ; the appetite is preserved ; there is no unusual 
thirst ; and the bowels continue regular. 

It is said that idiotcy is apt to occur in cases which last for a 
number of years. 

The course of the disease is acute or chronic. In a large 
majority of cases it. is acute, the symptoms becoming more and 
more violent until they reach their height, when they remain sta- 
tionary for a time, and then subside and disappear under the in- 
fluence of treatment, or in the natural course of the malady. In 
fatal cases the symptoms are constantly aggravated ; the move- 
ments become so violent as to make it necessary to secure the 
child in bed, or in a straight jacket ; the patients, deprived of 
sleep, become feeble and emaciated ; the respiration becomes diffi- 

37* 



438 CHOREA. 

cult ; intelligence is abolished ; the pupils are contracted ; and the 
child dies. 

The duration is irregular, varying in acute cases between one 
and three months. The average duration is probably about six or 
nine weeks. In very slight attacks it may be much less. The 
duration of chronic cases is from months to years. In fatal cases 
the duration is sometimes very short. In one it was nine only, 
and in another twenty-seven days. 

It should not be forgotten that relapses are very common. 

Nature of chorea. — Some doubt exists as to the nature of the 
disease under consideration. That it is not an organic affec- 
tion of the nervous centres is clear from the whole history of the 
malady, from the great variety of lesions found in some instances, 
and from the total absence of anatomical changes in others. Dr. 
M. Hall regards it as an affection of the true spinal system, but in 
this he is opposed, and I think, with reason, by Dr. Carpenter, 
who says [Principles of Human Physiol. Lond. note, p. 234) : 
" It is true that there is considerable irregularity in the ordinary 
reflex actions ; but the irregularity is still greater in those to which 
volition or emotion are the stimuli. Moreover, the body is at rest 
during sleep ; and the ' spinal system never sleeps.' " Dr. C. is 
disposed to think that the cerebellum, which is the organ which 
co-ordinates and harmonizes the muscular motions, is probably 
the chief seat of the disease, and this, it appears to me, is the most 
reasonable theory which has as yet been offered in regard to the 
real nature of the affection. 

The diagnosis of chorea cannot, it seems to me, be difficult, and 
I shall therefore make no remarks upon it. 

Prognosis. — Idiopathic, simple chorea, independent of organic 
disease of the nervous centres, and of complications, is rarely fatal. 
Nevertheless, even under these circumstances, it sometimes termi- 
nates fatally, since MM. Rufz, Legendre, and Rilliet and Barthez, 
have each met with an instance. When the disease, on the con- 
trary, is occasioned by an affection of the brain or spinal marrow, 
it becomes very dangerous. The degree of danger will depend on 
that of the disease which determines the chorea. 

Dr. Copland states that he has met with three or four fatal cases , 



TREATMENT. 439 

that Dr. Prichard has recorded four ; and that Dr. Brown refers to 
three in his practice ; but he does not inform us whether they were 
idiopathic, complicated, or symptomatic. 

Whenever, in a case of chorea, the convulsive motions become 
incessant, and the respiration embarrassed, and still more when 
subsultus tendinum takes the place of the choreatic movements, a 
fatal termination is greatly to be apprehended. 

Treatment. — Many different plans of treatment, and a great 
variety of drugs have been proposed for the cure of the disease 
under consideration. These facts alone may serve to teach us that 
the effects of treatment are not clearly appreciated, and also, when 
taken in connexion with the circumstance that fatal cases are rare, 
that the disease tends naturally to recovery in a good proportion 
of the cases. This feature of the natural history of the disease is 
shown also by the evidence given by Dr. Bardsley, senior, who 
mentions, that in the Manchester Infirmary, notwithstanding the 
variety of treatment adopted by successive practitioners, an in- 
curable case had not presented itself in the course of thirty-three 
years. ( Tweedie's Lib. Pract. Med. Am. Ed., vol. ii, p. 46.) 

It seems to me that the only rules to be laid down for its 
treatment are those which apply to all the convulsive affections 
depending on functional disorder of the nervous system. These 
are attention to the general health, to the removal of any local 
derangement or disease which may exert an evil influence upon 
the nervous system, and the employment of such remedies as have 
been found to exert a controlling effect upon spasmodic and con- 
vulsive affections generally, and particularly antispasmodics. 

I shall consider, under different heads, the various means that 
have been recommended, endeavouring in the course of my re- 
marks to distinguish the cases to which each remedy is best 
adapted. 

Purgatives. — This class of remedies has been extensively em- 
ployed, and often exclusively relied upon by some very high autho- 
rities, especially by English writers. When relied upon exclusively 
in the treatment, an active cathartic is given every day, or every 
second or third day ; and there can be no doubt that many cases 
have recovered under this plan. It seems to me, however, that 



440 CHOREA. 

they ought to be used, in general, only to such an extent as may 
be necessary to secure a soluble and healthful condition of the 
bowels. When, on the contrary, the stools are natural and health- 
ful in all respects, it can scarcely be proper to employ powerful 
purgatives in the treatment of the disease. I would, therefore, re- 
sort to them only when there is constipation, or when the dis- 
charges present some unnatural appearances as to colour, odour, 
etc. Under the latter circumstances we may resort to any of the 
somewhat active substances of the class, as cream of tartar and 
jalap, sulphate of magnesia, rhubarb, aloes, etc. When the dis- 
charges from the bowels are clay-coloured, or dark and offensive, 
when the mouth is pasty, the tongue loaded with a thick yellowish 
fur, and the breath heavy, it is generally most proper to employ a 
mercurial. Dr. Copland advises that we should commence with 
the exhibition of a full dose of calomel, either alone or with other 
purgatives, or followed by them in five or six hours. He adds 
that the doses of calomel ought not to be frequently repeated in the 
disease, and thinks that it is not serviceable "to continue purga- 
tives long, without either exhibiting them with a bitter tonic or 
antispasmodic remedy, or with both, or alternating them with those 
remedies." 

Bloodletting can rarely be necessary. The only circumstances 
that would seem to call for its employment, are severe headache, 
with signs of determination of blood to the brain, and the occur- 
rence of the disease in a girt at the age of puberty, in whom there 
is reason to suspect that the cause of the disorder is the want of 
the menstrual function. In both these cases it is best to employ 
local bleeding ; in the first to the temples, or behind the ears ; in 
the last to the groins and upper parts of the thighs. It is proper 
to remark, however, that general bleeding has been recommended 
and practised by some most distinguished physicians. The evi- 
dence of late observers seems to show, nevertheless, that it is 
rarely, if ever, necessary, and there must be many cases in which 
it would only increase the already excessive excitability of the 
nervous system. 

Antispasmodics are amongst the most important remedies we 
have to oppose to the disease. The weight of evidence seems to 



TREATMENT. 441 

show, indeed, that they, in conjunction with a moderate use of 
purgatives, and careful regulation of the hygienic conditions of the 
patient, ought to constitute the treatment in the great majority of 
cases. Of the various remedies of this class that have been em- 
ployed, those which seem to have exerted the most beneficial in- 
fluence, are valerian, assafcetida, oxide of zinc, camphor, and the 
root of the cimicifuga or black-snake root. 

Of these different remedies the one most employed in this city 
at present is, I think, the cimicifuga. This was first introduced 
into use by Dr. Jesse Young, and is now extensively employed 
and much relied upon. Dr. Wood (Pract. of Med. vol. ii, p. 755,) 
says : " I have in repeated instances found it of itself adequate to 
the cure of the disease." I have employed it myself only in two 
instances. In one of these the child recovered under its use, whilst 
in the other it failed entirely. In the latter case recovery afterwards 
took place under the use of iron, the sea-bath, and in the course of 
time. The cimicifuga is given in powder, tincture, or decoction, 
and should be continued for several weeks in gradually increasing 
doses, until some visible effect is produced, as nausea, headache, 
vertigo, or disordered vision. The usual doses are from half a 
drachm to a drachm of the powder, from one to two ounces of the 
officinal decoction, or one or two drachms of a saturated tincture, 
given three times a day. 

The French authors chiefly recommend valerian, oxide of zinc, 
and assafoetida. Of these the one which has the highest reputa- 
tion is valerian, and from the evidence adduced in its favour, there 
can be no doubt that it exerts a very beneficial influence upon 
the disease. It may be given in the form of powder, infusion or 
fluid extract. The dose of the powder is from twelve to eighteen 
grains in the day, to commence with, to be rapidly increased to 
several drachms, as the stomach becomes accustomed to it. It 
may be given in honey or preserve. I should prefer the fluid ex- 
tract, of which half a teaspoonful may be given to a child eight or 
ten years old, three times a day, and the quantity gradually in- 
creased. The oil of valerian is employed by some practitioners. 
Oxide of zinc is given in doses of a grain every three hours to 
children eight years old, and is much relied upon by some practi- 



442 CHOREA. 

tioners. Assafoetida is recommended both by English and French 
writers. It is best given in pill, on account of the nauseous taste 
of the mixture. Two three-grain pills may be given to a child of 
four or six years of age, three times a day. Dr. Bardsley gave it 
by injection, in combination with laudanum, every evening, after 
using musk and camphor through the day. 

Narcotics have been recommended by some writers. Those 
which are most employed are opium, belladonna, stramonium, and 
of late, strychnia. Substances of this class are seldom, however, 
made the basis of treatment. Opium is useful in some cases in 
which the agitation is very great, so that the sleep of the child is 
much disturbed, but it is seldom necessary except as an adjuvant 
to other means ; and the remark applies equally to other remedies 
of the class. Within a few years M. Trousseau has employed 
with success the sulphate of strychnia. It seems to me, however, 
that a remedy so dangerous as this, ought not to be employed in 
the cases of children, except when urgently necessary, which is 
certainly not true of chorea. 

Tonics. — Whenever the disease occurs in debilitated and ane- 
mic individuals, remedies of this class prove of great efficacy. 
The ferruginous preparations are those most clearly indicated under 
the circumstances. Any of them may be selected. The best 
are the subcarbonate, Vallet's pills, and the pure metallic iron, 
(Ferium per hydrogen.) Quinine is also recommended when the 
patient is feeble and weak. It may be given alone or in combination 
with iron. The citrate of iron and quinine would form a very 
good prescription under the circumstances mentioned. 

The cold plunge and shower bath have also been resorted to by 
a number of practitioners, and there is evidence to show that they 
have often proved useful. The cases in which they are used j j 
should be selected, however. They ought not to be employed un- 
less followed by full reaction, nor unless the child is willing to 
take them. When the use of the bath terrifies or shocks the patient 
greatly, it cannot be proper. A warm or tepid bath used once 
a day, or every second day, would always be useful in promoting 
the general health, when the cold bath is not borne well. 



TREATMENT. 443 

Sulphur baths, made by dissolving about four ounces of the sul- 
phuret of potassium in an ordinary bath, were employed with very 
good effects by M. Baudelocque. The bath was administered every 
day, during a period of from half an hour to an hour. Rilliet and 
Barthez state that eight of the cases observed by them were treated 
almost exclusively by this means. Five of these recovered with 
considerable rapidity, whilst in three, the treatment failed entirely, 
and even seemed to exasperate the choreatic movements. 

A great variety of remedies besides those we have mentioned 
have been employed, and have more or less evidence in their 
favour. Amongst them are sulphate of zinc, nitrate of silver, sub- 
nitrate of bismuth, iodine, and a host of others which it is useless 
to enumerate. The sulphate of zinc has undoubtedly proved effica- 
cious in some instances. About two grains may be given at first 
three times a day, and gradually increased to six or eight if the 
stomach bears the remedy well. 

Counter-irritation to the spine, in all its shapes, from pustulation 
with tartar emetic, issues, and blisters, down to frictions with coarse 
towels, have been proposed and employed in the treatment. It 
seems to me that the use of any but the milder remedies of this 
class is unnecessarily harsh and cruel, except when the disease is 
evidently dependent upon an affection of the brain or spinal marrow. 
The great majority of cases will recover perfectly well without a re- 
sort to such violent means, and they ought therefore to be avoided. 
Electricity has been resorted to, and apparently with good effects 
in some instances, and it might therefore be tried when other and 
simpler means fail, or in conjunction with these means. 

Hygienic treatment. — The management of the hygiene of the 
patient is quite as important as any other part of the treatment. 
The diet should be arranged to suit the particular condition of the 
individual, and with a view to procure and maintain the most 
healthful possible state of the digestive apparatus. It should always 
be light and easily digestible, in order that neither the stomach nor 
bowels may be oppressed and deranged by the products of an im- 
perfect digestion. When the stomach is weak and dyspeptic, the 
food ought to consist for some days chiefly of preparations of milk 
and bread, whilst in the mean time, some tonic remedy is ad- 



444 CHOREA. 

ministered internally, in order to invigorate the power of the organ. 
As the digestive function becomes stronger, the child ought, as a 
general rule, to be put upon the use of the kind of diet most likely 
to promote general health and vigour of body. It ought to con- 
sist, in my opinion, of bread, milk, the plain, wholesome meats, 
and simple vegetables. Coffee and tea, and ail other nervous sti- 
mulants had better be avoided. The meats ought to be mutton, 
beef, chicken, or turkey. There are few vegetables, besides rice 
and potatoes, which are suitable under the circumstances. All 
candies, preserves, unripe, coarse, or dried fruit, hot bread and 
cakes, except the very simplest, ought to be withheld. 

Of dress I need merely say that it must be suited to the season. 
Exercise, or at least, exposure to fresh air and insolation, are of 
the utmost consequence. When the disease is so violent as to pre- 
vent the child from walking, it ought to be taken to ride as 
often as possible. In cases which seem connected with a debili- 
tated and anemic condition of the constitution, removal to the 
country, and particularly to the seaside, will often effect a cure with 
great rapidity. Whenever, indeed, a patient inhabiting a large city 
or town can be conveniently taken to the seaside in the summer, 
it ought to be done, as this course is useful not only at the time, 
but by strengthening and invigorating the constitution for the future, 
lessens the danger of a relapse. 



CLASS IV. 

ERUPTIVE FEVERS. 
ARTICLE I. 

SCARLET FEVER OR SCARLATINA. 

Definition ; frequency ; forms. — Scarlet fever is an epidemic 
and contagious exantheme, characterized by continued fever ; by a 
scarlet rash, which appears on the second day of the disease, ends 
about the sixth or seventh, and is followed by desquamation ; and 
by simultaneous inflammation of the tonsils, and of the mucous 
membrane of the mouth and pharynx. 

The frequency of the disease is exceedingly variable in different 
years, because of its epidemic* nature. I find by reference to the 
tables of mortality of this city, published by Dr. G. Emerson, 
(Am. Journ. Med. Sciences, vol. i, 1827,) that in the twenty 
years from 1807 to 1827, there were 93 deaths from the disease 
under twenty years of age. In thirteen of these years, from 1 to 
8 deaths occurred per annum; in five successive years, 1812 to 
1817, not a single death is reported, while in the two remaining 
years, 1820 and 1821, the deaths were 30 in the former, and 13 
in the latter. In another communication in the same journal 
(November, 1831), Dr. E. gives the mortality from the disease 
under twenty years of age, during the four years from 1827 to 
1830, inclusive. In 1827 there was one death; in 1828 none; in 
1829 nine ; and in 1830 forty. 

It is, I believe, a decidedly less frequent disease on the whole 
than measles, though when short periods of time are taken, the 
deaths from scarlatina sometimes preponderate. Guersent and 
Blache (Diet, de Med. t. 28, p. 173), state that it is less frequent 

38 



446 SCARLET FEVER. 

than measles or variola. They added together the cases of erup- 
tive fevers collected in 1838 and 1839, by Roger, Rilliet and 
Barthez, and Barrier, in the Children's Hospital at Paris, and found 
that there had been only 157 cases of scarlet fever, whilst there 
were 267 of measles, and 213 of variola and varioloid. It appears 
from Dr. Emerson's paper that in the period of twenty years re- 
ferred to, there were only 93 deaths from scarlet fever, whilst there 
were 654 from measles, under twenty years of age. 

To show how uncertain the proportion is, however, we need 
only quote from Dr. Condie's note, the fact that whilst in the ten 
years preceding 1845, there were 2154 deaths from scarlet fever 
in this city, under fifteen years of age, there were only 574 from 
measles. 

The forms of the disease generally enumerated are the simple, 
anginose, and malignant. Authors differ widely in their descrip- 
tions of these three forms. Thus most of the English authors in- 
clude in the simple form only the cases in which there is no affec- 
tion of the fauces, while the anginose form includes all in which 
there is any throat-affection whatever. Rayer, on the contrary, 
describes under the head of the simple form the cases in which the 
throat-affection is mild, while he considers the anginose form to 
be that in which a pseudo-membranous angina occurs. Again, 
the descriptions of the malignant form are vague and uncertain, 
some including under this form only the rapidly fatal cases in 
which cerebral symptoms are present, while others include those 
also which are rendered malignant by the occurrence of pseudo- 
membranous angina. 

I have been tempted by the confusion which exists in the de- 
scriptions of these different forms, and by the belief that the divi- 
sion is faulty and imperfect, to seek some other more consonant 
with what my own observation has taught me. I have determined 
therefore to describe two forms or degrees of the disease, which I 
shall designate regular and grave. 

By the term regular I mean the typical form of the disease, or 
that which it assumes in the majority of the cases. In this form 
the angina is simple and the eruption regular in all respects ; there 
is no predominance of one set of symptoms over another, but all 



FORMS CAUSES. 447 

hold a due relation to each other. This form includes the scarla- 
tina simplex of all writers, and many of the cases of scarlatina 
anginosa of the English authors. 

Under the title of grave form, I shall describe the cases which 
depart from the regular course of the disease and are rendered 
dangerous by the occurrence of severe symptoms which do not 
belong in the same degree to the simple affection. I shall subdi- 
vide this form into two varieties, the grave anginose, which will 
include all the cases accompanied by pseudo-membranous, ulcera- 
tive, or gangrenous angina; and the grave cerebral, which will 
include those marked by the early occurrence of dangerous cere- 
bral symptoms. This form includes some of the cases of scarla- 
tina anginosa, and all those of the scarlatina maligna of writers, 
dividing, however, those in which pseudo-membranous angina de- 
termines the type of the attack, from those in which the cerebral 
or nervous symptoms give the stamp to the malady. 

Causes. — The two chief causes of scarlatina are contagion and 
epidemic influence. Of these the latter is apparently by far the 
most active. Though the fact of the contagious character of the 
malady has been doubted by some it seems clearly proved by the 
evidence adduced by various writers, and in my personal expe- 
rience, I have several times known one child in a family to con- 
tract the disease from direct exposure to it, or from its presence as 
an epidemic in the community, and in five, seven, or nine days 
after the first fell sick, a second, a third, and even a fourth child, 
has taken the disease from the first. In other instances, on the con- 
trary, it would seem that either several children in one family con- 
tract the disease nearly simultaneously from the epidemic influence, 
or else that the period of incubation is very short. For example 
in the course of the last winter, a child five months old, who had 
never been out of the house, was seized with the disease. On the 
second day after the eruption appeared on this child, his sister, 
between four and five years old, fell sick, and on the third day 
another sister, the only remaining child, of between two and three 
years of age. In the first of these cases the disease must have 
been contracted through the epidemic influence which was at that 
time prevalent in the city, since the child had in no way been 



448 SCARLET FEVER. 

directly exposed to it. In the other two, we must either suppose 
the cause to have been the same, or else that the period of incu- 
bation was only two and three days in the respective cases. 

The period of incubation is shorter than in the other contagious 
eruptive diseases. It may be stated to vary between two or three 
days and two or three weeks. Guersent and Blache are of opi- 
nion that in the majority of cases, it is from three to seven days. 
Rilliet and Barthez found that of 38 cases in which the time was 
recorded, it was between 2 and 7 days in 16, between 8 and 13 in 
14, and 15 and 40 in 8 cases. My own observation would fix it 
at about seven days in the majority of cases. 

It is impossible to fix with any certainty the length of time 
during which the power of imparting the contagion continues in 
the patient. Cazenove (Abrege Prat, des Mai. de la Peau, p. 54), 
states that it lasts throughout the period of desquamation, and 
that it would even seem to be most active at that time. 

The epidemics of scarlet fever vary exceedingly in their extent 
and violence. During the years 1841 and 1842, the disease pre- 
vailed very extensively in this city, and assumed a malignant 
type, so that in a considerable number of families two, three, and 
even four children perished within a very short period. Since 
that time it has been less extensively disseminated and much less 
fatal. 

The disease prevails at all seasons, but is most frequent 
in the spring and summer, and next in the autumn. It rarely 
occurs more than once in the same individual, but that it 
does so sometimes is proved by facts brought forward by dif- 
ferent authors. I once attended a child in this city with perfectly 
well-marked scarlet fever, attested by subsequent anasarca, who 
had had the disease two years previously under the care of my 
father, Dr. C. D. Meigs. 

Age. — Rilliet and Barthez state that it is most common from six 
to ten years of age. Of 70 cases that I have seen, in which the 
age was noted, 20 occurred under 3 years of age, 22 between 3 
and 5 years, 14 between 5 and 7, 12 between 7 and 10, and 2 
between 10 and 15. From this it would appear to be more common 
in the first five years than between the ages of five and ten, since 



CAUSES SYMPTOMS. 449 

of the 70 cases, 42 occurred in the former, and only 26 in the 
latter period. By uniting the statistical tables of Dr. Emerson 
with those of Dr. Condie (Dis. of Child. 2d ed. note, p. 86), I 
obtain the deaths from scarlatina in this city at different ages, for 
a period of thirty years. Their tables show clearly that the dis- 
ease is most common between the ages of one and five years. 
The total mortality under ten years, during the time stated, was 
2171, of which 130 were under one year of age, 411 between 
one and two, 1130 between two and five, and 510 between five 
and ten. The earliest age at which I have seen it perfectly well 
marked, was five months. 

The influence of sex seems not to have been determined with 
certainty. Dr. Tweedie {Cyclop, of Pract. Med. Art. Scarlatina), 
says it is most common in girls. Rilliet and Barthez, on the con- 
trary, state it to be more common in boys. Of 82 cases under 
15 years of age that I have seen, in which the sex was noted, 35 
occurred in males, and 47 in females. The truth is probably that 
under puberty it attacks the two sexes with about equal frequency, 
while after that age it is most common in females. 

Symptoms; course; duration. — Regular form. — To render 
the description of the symptoms more intelligible, I shall divide 
the course of the disease into the three stages of invasion, eruption, 
and desquamation. 

Stage of invasion. — The first symptom observed in the great 
majority of cases is fever, marked by considerable acceleration of 
the pulse, and heat of skin. In some few cases the fever is pre- 
ceded by the ordinary prodromes of febrile diseases, as languor, 
: lassitude, pains in the back and limbs, and slight rigors. Simul- 
j taneously with the fever, there is, in nearly all cases, more or less 
soreness of the throat. In all that I have examined, even those in 
which no pain was complained of, there has been redness, or red- 
ness with swelling, of the fauces. In a considerable number of 
cases vomiting occurs, or if not vomiting, some degree of nausea. 
There is complete anorexia ; the thirst is acute ; the bowels are 
usually in their natural condition, or slightly constipated. The 
child is quiet and dull, or else restless and irritable, and some- 
times there is delirium ; the face is generally flushed, and the eyes 

38* 



450 SCARLET FEVER. 

often slightly injected. The duration of these symptoms is irre- 
gular. They are said to last generally about a day, but they may 
continue either a shorter or longer period. I have often known 
them to continue less than a day, and very rarely more than 
two. 

Stage of eruption. — The eruption generally appears first on the 
face and neck, whence it extends rapidly over the whole surface. 
It continues to increase in extent and intensity, so as to reach its 
maximum about the third or fourth day. It appears first in minute 
dark-red points dotted upon a rose-coloured surface, which form 
patches of irregular shape, of considerable size, level with the 
skin, disappearing under pressure, divided at first by healthy por- 
tions of skin, but rapidly running together, and giving to large 
portions of the surface an uniform scarlet colour. The eruption 
is not generally equally diffused over the whole body, but is more 
marked upon one portion than another. It is generally very vivid 
upon the face and especially on the cheeks. It is often most in- 
tense on the back, and is there of a deeper colour than elsewhere, 
and not unfrequently assumes a purple hue. It is generally very 
well marked on the abdomen and thighs, and assumes in those re- 
gions a particularly bright tint. 

It does not always cover the whole surface, but in some very 
mild cases, and as we shall find when treating of the complications 
of the disease, in very severe cases, it may occur only in patches 
of moderate extent upon different portions of the body, leaving us 
at times in some doubt as to the real nature of the rash. 

The surface of the eruption is smooth and even to the touch, 
unless, as not unfrequently happens, it is accompanied by the de- 
velopment of miliary vesicles, or crops of minute pimples, or 
pustules. A certain degree of roughness is sometimes occasioned 
also by enlargement of the papilla? of the skin in various parts of 
the body, particularly on the extensor surfaces of the limbs; but 
these are evidently independent of the characteristic eruption. The 
skin upon some parts of the body, especially the face, hands, and 
feet, often presents a swollen appearance, rendering the move- 
ments somewhat stiff. There is in most cases a feeling of burn- 



SYMPTOMS. 451 

ing, irritation, and itching in the skin, the latter of which symp- 
toms increases as the malady progresses. 

The eruption generally reaches its height about the fourth day, 
and then remains stationary for one, or less frequently two days, 
after which it begins to decline. Its decline is marked by a dimi- 
nution in the intensity of the colour, which, from scarlet becomes 
red, then rose-coloured, and growing paler and paler, finally dis- 
appears entirely about the sixth, seventh, or eighth day. 

The symptoms which preceded the eruption do not subside on 
its appearance, but persist or are augmented. The febrile move- 
ment continues unabated ; the pulse is full, strong, and frequent, 
rising to 100, 120, 130, and even 160 ; the skin is burning hot, 
dry, and loses its softness and suppleness. ■ The expression of the 
face is generally natural. The eye is often animated, and slightly 
injected. The respiration is generally easy and natural, though 
sometimes when the fever is violent, it becomes quickened. The 
auscultation and percussion are natural, unless some complication 
exists. There is often a rather frequent cough, which is dry, and 
evidently depends on the guttural inflammation, and not on any 
bronchial or pulmonary affection ; it exists during the early period 
of the eruption, and declines with the inflammation of the fauces. 
The voice is seldom altered beyond having a nasal sound, so long 
as the disease continues simple and regular. If it become hoarse 
or whispering, it indicates a probable extension of inflammation 
from the pharynx to the larynx. The anorexia continues until 
the eruption begins to decline, and the thirst is acute up to the 
same period, when it moderates. At first the dorsum of the tongue 
is covered with a whitish or yellowish-white fur of variable thick- 
ness, while its tip and edges are of a deep red colour. After two 
or three days, and during the increase of the eruption, the coating 
just described disappears from the tongue, and its. whole surface 
assumes a deep red tint and a shining appearance, which makes it 
look like raw flesh. At the same time it is often much diminished 
in size from contraction of its tissues, and its papilla; become 
enlarged and projecting ; this condition generally lasts from six 
to ten days, after which the tongue returns to its natural state ; it 
is commonly moist throughout the attack. Vomiting rarely occurs 



452 SCARLET FEVER. 

in the regular disease ; the bowels continue nearly in their natural 
condition ; in some few cases slight diarrhoea occurs, but more 
frequently there is very moderate constipation which requires 
the use of mild laxatives. The abdomen is natural in most of 
the cases. Sometimes, however, there is slight tension and pain 
for a few days, which coincide generally with enlargement of the 
liver, or more rarely of the spleen. The urinary secretion is 
usually more or less reddened as in other febrile diseases. Early 
in the second, or even in the first stage, the fauces present the 
signs of inflammatory action ; the pharynx is reddened, and in 
some cases swelled ; the tonsils enlarge and become red ; the sub- 
maxillary and lymphatic glands are somewhat tumefied, and tender 
to the touch, and when the case is at all severe, deglutition is 
generally painful, and in some instances extremely so. The ab- 
sence of complaints of sore throat in a child, or the fact of its 
swallowing without hesitation or apparent difficulty, is no proof 
that angina does not exist, as I have always found upon examina- 
tion in a good light, much greater redness than natural, and in 
many instances redness and swelling combined. As the eruption pro- 
gresses, and the tongue loses its coat and becomes red, the inflam- 
mation of the pharynx usually augments ; the redness becomes 
deeper ; the tonsils are more swelled and painful, and dotted over 
with small white spots, or with thin, whitish, and soft false mem- 
branes. The throat-affection, however, is rarely severe enough to 
constitute a serious danger in simple regular scarlatina, while in 
many of the malignant cases, it is a frequent cause of a fatal ter- 
mination. During the eruption the nostrils are either dry and 
incrusted, or there is some coryza. The strength of the child is 
reduced for the time, but there are no signs of prostration, and the 
decubitus is indifferent. There is almost always more or less dis- 
order of the nervous system, sometimes amounting only to head- 
ache and restlessness, while in other instances there is great irri- 
tability, wakefulness, or delirium. 

Stage of decline and desquamation. — The eruption reaches 
its height, as already stated, about the third or fourth day, then 
remains stationary for one or two days, and afterwards declines 
gradually, so that no traces are left on the sixth, usually, or 



SYMPTOMS. 453 

at most in rare cases, on the ninth or tenth. The other symp- 
toms, both general and local, decline with the eruption ; the 
pulse loses its frequency, and falls to the natural standard ; the 
heat of the surface first subsides and then disappears, but the skin 
remains somewhat harsh ; the redness and swelling of the tonsils 
and pharynx diminish ; the spots of false membrane are absorbed 
or thrown off; the deglutition becomes easy if it have been difficult, 
and soon all signs of throat-affection vanish ; the tongue cleans off, 
becomes reddish and glossy, and after a time returns to its natural 
state. 

At the time that the subsidence of all the symptoms takes place, 
desquamation begins. It dates therefore in most cases from about 
the sixth day, though it may be either earlier or later. It com- 
mences in most of the cases on the face and neck, though in a few 
instances it appears first on the abdomen. It then extends gra- 
dually over the body and becomes general. About the thorax and 
abdomen it occurs in the form of minute points, like those which 
result from the desiccation of sudamina ; on the face it is in the 
form of thin light scales or squama?, while on the extremities 
large flakes of the epidermis become separated from the derm, 
and are removed by the child, or rubbed off by his movements in bed ; 
these flakes are sometimes so large on the hands and feet as to form 
complete moulds of the fingers and toes, or even of the hands and 
feet. The whole process usually occupies some ten or twelve 
days, but may be prolonged even into the third week. It is gene- 
rally accompanied by roughness and dryness, and some itching 
and irritation of the skin. Not unfrequently, the surface beneath 
the exfoliation is left tender and irritable for some time afterwards. 

Symptoms of the grave anginose form. — This is the form of the 
disease described by M. Rayer and Dr. Geo. B. Wood, amongst 
others, under the title of scarlatina anginosa. Most English authors 
include also under that title all the cases in which there is any 
pharyngeal inflammation whatever, whilst I have deemed it more 
correct to refer such cases to the regular form, so long as the in- 
flammation is not violent enough to constitute a complication or 
irregularity. In the form now about to be described, I shall, as 
before stated, include all the cases which are rendered dangerous 



454 SCARLET FEVER. 

and irregular, by the occurrence of pseudo-membranous, ulcerative, 
or gangrenous angina. 

This form begins generally with greater violence than regular 
cases of the disease. The disturbance of the circulation, heat 
of skin, and nervous symptoms are usually more marked. The 
redness and swelling of the fauces are found upon examination 
to be more considerable ; the difficulty and pain of deglutition 
are more complained of by older children, and are shown 
in those who are younger, by their refusal to swallow, by their 
crying upon making the attempt, and in some instances by a posi- 
tive inability to perform the movement. The false membrane is 
never, or very rarely, present on the first day of the attack. In 
most cases it is not found until the second or third, and often not 
before the fifth or sixth day. Rilliet and Barthez state that they 
have known it not to appear until the tenth and eleventh days. It 
appears first in small, thin, whitish, yellowish, or ash-coloured 
points or patches, on one or both tonsils, or the soft palate only, 
where it remains limited, or extends to the pharynx, which it may 
cover in whole or in part. The patches are of variable thick- 
ness and consistence, and adhere sometimes very slightly, and 
sometimes with considerable tenacity to the mucous membrane 
beneath. They may remain for a day, and then be thrown off 
not to be again produced ; or they may form in several successive 
crops, until the case is terminated ; or, as most frequently happens, 
they last three or four days, or more, and are then detached. The 
mucous membrane upon which they are seated is found in various 
conditions. It may present the redness and swelling indicative of 
severe inflammation, or it may be softened, ulcerated, and accord- 
ing to Guersent and Blache, gangrenous, though generally what 
have been supposed to be sloughs were in fact portions of altered 
false membrane. There is more or less fcetor of the breath, some- 
times amounting to a gangrenous odour, after the appearance. of 
the pseudo-membrane. The severity of the symptoms is in pro- 
portion to the extent and thickness of the false membrane. 

We have already seen that it is not uncommon to find ulcera- 
tions beneath the false membranes. In other cases of the grave 
anginose form, the throat-affection assumes very great violence 



SYMPTOMS. 455 

without the presence of any exudation whatever. In some of these 
the mucous membrane is of a deep red or even purplish hue, its 
consistence is softened, and it is swelled, and covered with a layer 
of grayish or sanious pus. The tonsils are enlarged, infiltrated 
with pus, softened, and easily break down under the finger. In 
other cases, in addition to the redness and softening, ulcerations 
are present. These may be superficial, amounting only to ero- 
sions, or they may extend through the mucous, and even sub- 
mucous tissue to the muscles beneath. They are generally seated 
in the pharynx, but may exist also in the tonsils, and in some 
rare cases extend into the larynx. In still more malignant attacks 
of the disease, we find evidences of gangrene of the pharynx. It 
is important to distinguish between those in which the pseudo- 
membrane becomes so changed as to assume the form of sloughs, 
and those in which the tissues of the pharynx are really gangrenous. 
The former constitute by far the greater number of the cases which 
have been generally regarded as instances of gangrene of the 
throat. That gangrene of these tissues does actually occur in 
some few cases, is proved, however, by the evidence of Dr. 
Tweedie, who says (Loc. cit. p. 650), that in malignant scarlatina 
" the membrane of the pharynx is sometimes of a dark, livid 
colour, and occasionally in a sloughing state," and by that of Guer- 
sent and Blache (Diet, de Med. Art. Scarlatine, p. 159), who state 
that they met with several instances of gangrene of the pharynx 
in the pseudo-membranous angina which prevailed in 1841. 

An almost constant accompaniment of the grave anginose form 
is inflammation and swelling of the sub-maxillary lymphatic glands 
and surrounding cellular tissue. The tumefaction is generally con- 
fined at first to the glands beneath the jaw, which become painful 
to the touch. After a short time it extends to the parts behind the 
angle of the jaw, and beneath that bone, until at last the sides of 
the neck and the throat are largely distended, so as to interfere 
with or even in great measure prevent the opening of the mouth, 
and by the pressure which they exert on the internal parts of the 
throat, to add to the difficulty of deglutition which already exists. 
In some cases the pressure is so considerable as to embarrass the 
respiration of the child. This swelling has been generally sup- 



456 SCARLET FEVER. 

posed to depend on inflammation of the parotid glands ; but MM. 
Bretonneau, Guersent and Blache, and Barthez and Rilliet, all 
state that parotitis is of exceedingly rare occurrence, and that the 
swelling in question depends nearly always on the causes just 
described. The last-named writers state, moreover, that the tume- 
faction of the cellular tissue is often of the nature of active oedema. 
The enlargement generally disappears, in favourable cases, in 
from three to twelve days, by resolution, while in others it termi- 
nates by suppuration of the glands and surrounding parts. 

Tn the form of the disease we are now considering, it is common 
to observe violent coryza, which may be either purulent or pseudo- 
membranous. It may appear from the very first, or not for seve- 
ral days after the eruption has commenced. The discharge is 
yellowish, granular, thin, very offensive, and highly acrid, so as 
to excoriate very much the upper lip. It sometimes flows in great 
abundance, and generally continues up to the moment of death, or 
until all the symptoms are moderated. 

Otorrhoza is another symptom of this form. It generally occurs 
simultaneously with the coryza. The discharge is at first thin 
and watery, much like that from the nostrils, and becomes gra- 
dually thicker as the case advances. The quantity is extremely 
variable. In some cases I have known it to fill the meatuses and 
conchae of both ears, and then to flow out and make large stains 
upon the pillow, or to collect very rapidly after being wiped away. 
It is, like the coryza, an unfavourable symptom, as it is a mark of 
the grave form of the disease, and because, if the child recovers, 
it is very apt to result in deafness, which is but too often per- 
manent. 

These symptoms, coryza and otorrhcea, sometimes exist also in 
cases of the regular form, but they do not then assume the pecu- 
liar characters which they present in grave cases. The discharges 
are much less abundant, and the mucus or pus healthy and 
scarcely offensive in smell ; they last but a short time, and are very 
rarely accompanied at the time, or followed by more than a slight 
degree of deafness. 

The eruption is generally stated to appear later than in the re- 
gular form, and often to be less vivid and less extensive. It is 



SYMPTOMS. 457 

also said to occupy only portions, and not the whole of the body, to 
occur in irregular patches, or to appear and disappear alternately. 
This has not been the case in the instances which I have seen. 
In all but one of these, nine in number, the eruption occurred 
early, generally within twenty-four hours from the onset. It was 
of a deep brick-red or livid colour, and covered the whole surface. 
In the exceptional case, the eruption did not take place until the 
seventh day, when it appeared in patches on the wrists and knees. 
On the eighth day it extended to the rest of the extremities and 
abdomen, and on the ninth was general, and of a rather dark hue. 
The general symptoms are more severe in this than in the re- 
gular form. It sometimes happens that for one or two days, or 
even longer, the case promises to be one of the latter kind, but then 
suddenly assumes the threatening features of the form under con- 
sideration. The fever is usually intense, the pulse being full and 
strong, and rising very soon after the onset to 140, 150, or 170; 
the skin is very hot and dry; there is more restlessness and irrita- 
bility than in the regular form, and after one, two, or three days, 
appears a strong disposition to delirium and stupor, not unfrequently 
merging into coma. The respiration is accelerated, and in many 
instances, owing to the throat-affection, laboured and difficult. In 
most of the cases, a loud gurgling, which is very characteristic, is 
heard in the throat, particularly when the child is asleep or dozing. 
This depends in part upon the collection of viscid and tenacious se- 
cretions in the fauces, which sometimes embarrass the respiration 
so much as to make it necessary to remove them with a mop, or 
by the operation of an emetic, and in part upon the existence of 
the coryza of which we have spoken. This latter symptom is one 
of very serious consequence in infants, as in them, it alone may 
cause death, and always adds very much to the danger. There is 
generally some cough, which may be frequent and troublesome, 
though not usually so, unless there be a disposition to laryngeal 
complication. The voice is hoarse, guttural, and sometimes whis- 
pering. When the cough is very frequent, and still more, when 
it becomes hoarse and croupal, in connexion with hoarse or whis- 
pering voice, or aphonia, there is great reason to fear the extension 
of the exudation into the larynx, which constitutes an almost fatal 

m 



4 r )8 SCARLET FEVER. 

accident. The face is deeply flushed at first, and the expression 
anxious. If no improvement take place, the case, in four or five 
days, or even less, assumes a still more threatening aspect. The 
pulse becomes very rapid and small ; the restlessness and delirium 
pass into drowsiness or coma ; the tongue becomes brown and dry ; 
the teeth are covered with sordes ; the lips are dry, cracked, and 
bleeding ; diarrhoea is apt to occur ; and the patient dies in from 
three to ten days, in a perfectly well-marked typhous condition. 
In other instances, on the contrary, the case runs on from week to 
week, and at- last, after an illness of four, five, or six weeks, the 
child either dies, or recovers after all chances for life seemed to 
have been lost. 

Laryngitis has been supposed by some persons to be a frequent 
complication of the disease, while others assert that it rarely, if 
ever, occurs. Bretonneau has never met with it. Rayer says he 
does not know that the exudation has ever been found in the larynx 
or trachea. Tweedie [Cyclop. Pract. Med. Art. Scarlatina, p. 640) 
states that in the dissections he has made he has not seen an in- 
stance of the membranous exudation extending into the larynx. 
That it does sometimes occur, however, is proved beyond a doubt by 
the evidence of MM. Guersent and Blache, Rilliet and Barthez, and 
others, and by my own observation. Rilliet and Barthez report 
three cases in which it was found in the larynx after death. These 
gentlemen state, however, that they have never observed the pecu- 
liar symptoms of croup. This does not accord with my own ex- 
perience, for in one of the cases that I have seen, all the peculiar 
symptoms of that malady were present during life. The subject 
of this case was a boy two years of age. A few days after the 
invasion of the disease, a severe and extensive pseudo- membranous 
angina was developed. This was soon followed by all the symptoms 
of croup, — hoarse cough, stridulous respiration, weak, feeble 
cry, dyspnoea, and whispering voice, which lasted about five days, 
when the angina and croupal symptoms both very much diminished, 
and the child seemed in a fair way to recover ; suddenly, however, 
extensive tumefaction of one side of the neck took place, and he 
died in twenty-four hours. Unfortunately no examination could 
be made. The symptoms which indicate a disposition to implica- 
tion of the larynx are frequent, hoarse and croupal rough, hoarse 



SYMPTOMS. 



459 



and whispering voice or cry, aphonia, and dyspnoea with stridu- 
lous respiration. 

Symptoms of the grave cerebral form. — This form may exist as 
such from the commencement of the attack, or may supervene 
upon the regular or grave anginose form. In the majority of 
the cases that I have met with, the invasion has been altogether 
different from that of either of the other two forms. Of ten 
cases that I have seen, eight began with cerebral symptoms, 
while two presented for three or four days the characters of the 
regular disease, after which the cerebral symptoms made their ap- 
pearance, and soon led to a fatal termination. 

The cases which began with cerebral symptoms were very 
much the most violent attacks of the disease that came under my 
observation. The onset was in some instantaneous. In one, the 
little patient, a girl two years old, whose brother and sister had 
been sick for some days with scarlatina, was put to bed in the 
evening in her usual health, which was strong and vigorous. She 
slept quietly through the night, but was found by the mother the 
next morning in a state of drowsiness, violent fever, and covered 
with a deep-red scarlatinous rash. She soon became comatose, 
and died on the third day. In another case, a boy eleven months 
old was a little fretful in the afternoon, but was put to bed in the 
evening as usual, and went to sleep. About ten o'clock the nurse 
heard a rustling in the bed, and on going to it, found him in a 
violent general convulsion. The next morning he was covered 
with a scarlet rash, which became deeper and deeper as the dis- 
ease went on. On the second day he was nearly insensible, and 
had frequent attacks of convulsions ; on the third day he had re- 
traction of the neck, with spasmodic twitchings, and at the end of 
that day, died in a state of coma. In a third case, a boy six years 
old, whose sister had been sick for a week with a simple regular 
attack, went to bed well. At three o'clock in the morning, he was 
attacked with vomiting and purging, paleness and coolness of the 
skin, and great exhaustion. At nine o'clock he was drowsy and 
dull, the skin pale and cool, and the pulse extremely rapid ; the 
vomiting and purging had ceased ; at 12 m. he was comatose and 
had a convulsion. From this time he continued comatose until he 



460 SCARLET FEVER. 

died at 6 p.m. of the same day, after an illness of fifteen hours. 
In a fourth instance, the invasion was that of croup ; after a few 
hours came on coma and convulsions ; patches of eruption then 
appeared on the trunk, and death occurred in twenty-four hours 
from the beginning. The child, a boy five years old, was thought 
to be so well the afternoon of the day he was taken sick, that he 
had been sent out on a visit to a relation, and while there fell sick. 
In a fifth case the onset was sudden, with violent fever, drowsiness, 
deep suffusion of the skin, and in a few hours insensibility, then 
genera] convulsions, and death in thirty-six hours. In a sixth, in 
a boy four years old, the attack came on with vomiting, paleness, 
drowsiness, and then a scarlet rash ; after a few days, coryza and 
otorrhcea occurred ; there was dry cracked tongue and lips ; in 
the second week, the child was comatose with occasional attacks 
of extreme jactitation, and the most violent hydrocephalic cries, 
which condition lasted ten days. After this there was diarrhoea, 
extreme emaciation, loss of speech, and entire deafness. Gra- 
dually, however, the fever disappeared, the tongue cleaned off*, 
and intelligence very slowly returned ; in the sixth week con- 
valescence was firmly established, and the child recovered per- 
fectly with the exception of his hearing, which remained very dull 
in consequence of the perforation of both membranoe tympa- 
norum. 

In this form of the disease, therefore, the symptoms are of the 
most virulent character. The onset is sudden. The child passes 
within a few hours from a state of apparent health, into one of the 
extremest danger. Most of the cases begin with violent fever, 
and great depression of strength. The pulse soon becomes very 
rapid (140, 150, 180), or so quick that it cannot be counted, and 
at the same time is small and often irregular. The skin is dry 
and burning hot in some parts, in others cool or even cold. There 
is generally nausea or vomiting, which is sometimes violent and 
constant. This is accompanied in some cases, but, in my experience, 
only in the severest of all, by colliquative diarrhoea and mete- 
orism. Delirium often exists from the first, or else there is drow- 
siness and dulness of intelligence, verging gradually into coma. 
In the most violent cases, the stupor or coma alternate with con- 



SYMPTOMS. 461 

vulsions, which may cause a fatal termination in eighteen, twenty- 
four, or thirty-six hours. In cases rather less violent, the fever 
and irregular heat continue ; the cervical and sub-maxillary gan- 
glions and tonsils, become swelled ; the fauces are of deep red 
colour, and generally very much tumefied, from inflammation and 
infiltration, and there is considerable difficulty of deglutition. 
Generally the tonsils, and later in the attack the soft palate and 
pharynx, are covered with pseudo-membranous exudations, which 
may be in the form of cheesy, pulpy, slightly adherent flocculi, or 
in that of yellowish- white, tougher and more adherent patches. 
The nostrils at the same time are reddish and dry, and often 
incrusted, from the drying of the secretions of the part. The 
respiration is accelerated, and sometimes rendered very difficult by 
the swelling of the fauces, or by the viscid secretion which clogs 
those parts. The countenance is flushed and heated, or pale and very 
anxious. The eruption varies according to the violence of the case. 
In the severest one that I saw, that which proved fatal in eighteen 
hours, no eruption whatever was perceived, and we only knew it to 
be scarlatina by the characters of the other symptoms, and by the 
fact that the sister of the boy had been sick in the same house with 
the disease for a week. In the case which terminated in twenty-four 
hours, the eruption showed itself in the form of scarlet patches about 
the face and upper part of the body, twelve hours after the onset. In 
the other eight cases, which lasted not less than three days, the 
eruption was perfectly well marked. It covered the whole surface, 
was at first scarlet in colour, soon ran into a deep red, and then 
became violet or purplish. M. Gueretin (Arch, de Med. t. i, p. 
292, 1842), in his account of the acute malignant form which he 
witnessed, states that the eruption was nearly constant. In all 
my cases it occurred within twenty-four hours from the invasion, 
while in those of M. Gueretin, it appeared within twenty-four or 
forty -eight hours, or as more frequently happened, not until the 
fourth or fifth day. * 

If no favourable change takes place, the patient grows weaker 
and weaker; the delirium continues, or is replaced by coma ; sub- 
sultus tendinum, rigidity of the limbs, spasmodic twitchings or 
general convulsions, make their appearance; the eruption becomes 

39* 



462 SCARLET FEVER. 

more and more livid ; the pulse grows smaller, more frequent, 
and irregular; respiration is more embarrassed; deglutition be- 
comes impossible ; and the patient dies in from three to seven or 
nine days. In some few instances the child struggles on for several 
weeks, and dies in a state of utter exhaustion, or having a con- 
stitution of great power of endurance, at last surmounts the dis- 
ease and recovers. 

The duration, as we have already seen, is variable. Of the ten 
cases of the grave cerebral form that I have met with, one proved 
fatal in 18, one in 24, and one in 36 hours. Of the remaining 
seven, four died on the third day, one on the seventh, one at the 
end of the fifth week, and the last recovered after an illness of six 
weeks. 

Complications and sequelce. — Dropsy. — This is one of the most 
frequent and important sequelae of the disease. It occurred in a 
fifth of the cases of Rilliet and Barthez, and in seven of the 82, or 
about a twelfth of those observed by myself. It occurs generally in 
the course of the second or third week of the disease, and during the 
process of desquamation. It is thought to follow cases of moderate 
severity much more frequently than those of a grave character. 
Dr. Tweedie states that it has never been observed to succeed 
a malignant attack. This does not, however, accord with my own 
experience, since of the seven cases that I have seen, two occurred 
in the course of the grave anginose form of the disease. The 
effusion may attack any one of the cavities or tissues of the body, 
or all at once. The most common form in which it appears is 
anasarca, after which the most frequent are, in the order in which 
they are mentioned, oedema of the lung, hydrothorax, ascites, hy- 
dropericardium, and hydrocephalus. The exciting cause of the 
dropsy is now generally believed to be cold, contracted generally by 
exposure to air and moisture, at too early a period. I have rarely 
known it to occur when the patient has been confined to the cham- 
ber or house, until after the twenty-first day ;* while, on the other 
hand, I have seen it follow immediately upon a ride in cool weather 
on the fourteenth day, the child having apparently been conva- 
lescent for several days before. I have known it to occur also 
when the child has been allowed to run through the house exposed 



COMPLICATIONS SEQUELS. 463 

to draughts from open doors and windows. I am in the habit now 
of always directing the mother or nurse to keep the patient con- 
fined to the chamber for three weeks from the onset of the disease, 
or if it be allowed to run through the house, to take care to have 
it well clothed, and to keep the windows and doors carefully closed 
should the weather be cold or cloudy. It is very often dependent 
on disease of the kidneys. Rilliet and Barthez state that they 
found the characteristic renal lesions of Bright's disease, in more 
than half of all their cases of dropsy, and in more than two- 
thirds of those of anasarca. M. Legendre, on the contrary, 
ascribes it to simple ordinary inflammation, or congestion of the 
Sidneys. 

The symptoms which precede and accompany this complication 
are languor, lassitude, irritability, loss of appetite, restless sleep, 
and after a short time fever, with frequent, corded pulse, and hot 
dry skin. In some cases, however, the fever is very slightly 
marked, and the effusion is preceded only by the other symptoms 
just detailed. Sometimes there is nausea and vomiting also, and 
generally a moderate degree of constipation. The effusion usually 
commences in the face, and extends thence to the hands and feet, 
and is either limited to these parts, or spreads over the whole sur- 
face, and gradually to the internal organs. In some instances, the 
effusion takes place with great rapidity, affecting the cellular tissue 
and various internal organs simultaneously, and causing a fatal ter- 
mination in a very short space of time. Guersent and Blache 
have known it to end fatally in twelve, fourteen, or thirty-six hours, 
though more commonly it runs on for one or two weeks, or even 
longer. In six of the seven cases that [ have met with, the form 
of the effusion was anasarca, of which all but one recovered. In 
the seventh case hydrocephalus occurred suddenly several days 
after full convalescence from anasarca, and the child died in 
twenty-four hours after the most frightful general convulsions. 
The skin where the effusion has taken place, is firm, hard, and 
elastic to the touch, does not generally pit, and is of a dull white 
colour. In very mild cases where the effusion is slight, I have 
been able to determine the cause of the fever only by slight 
swelling of the face, particularly of the eyelids, and by a little 



464 SCARLET FEVER. 

puffiness of the backs of the hands and feet. When the effiusion 
attacks the thoracic organs, its presence is to be detected by the 
dyspnoea, which is sometimes extreme, and by the physical signs. 
Hydrocephalus is not an uncommon form of the affection. When 
it does occur it generally affects the ventricles, and more rarely, 
the sub-arachnoid tissue. It occasions drowsiness, dilatation or 
contraction of the pupils, and sometimes the most violent convul- 
sions, and may prove rapidly fatal. 

In regard to the appearance of the urine, a subject of great in- 
terest and importance, it may be stated that it is usually of a blackish, 
or more or less dark red colour, in the first few days after the 
appearance of the dropsy. After eight or nine days the colour 
generally becomes brownish, and as the case progresses and ap- 
proaches a cure, the fluid becomes less and less dark in colour, 
until about the fifteenth or twentieth days, when it is usually as 
pale or paler than in the natural condition. The discoloration 
just described is said to depend on the presence of blood in the 
urine, which may be easily ascertained by examination with the 
microscope. 

At the same time that the urine is discoloured, it is more or 
less turbid, especially when first voided, and though it becomes 
clearer after a while, from the deposit of little clots or reddish or 
whitish flocculi at the bottom of the vase, it never becomes entirely 
limpid. The specific gravity is somewhat diminished, but not to 
the same extent as in Bright's disease. 

M. Legendre (from whom this account is chiefly taken,) states 
that in the fourteen cases analyzed by him, the urine was always 
coagulable by heat and nitric acid. The precipitate varied, how- 
ever, in quantity and appearance, according to the colour of the 
urine, and distance of time from the invasion of the anasarca. 
Very abundant when the blackish or reddish colour indicated 
the presence of a large quantity of blood ; the coagulum diminished 
as the urine became lighter coloured. When the urine contained 
much blood, the precipitate obtained consisted of a number of floc- 
culi, which rapidly fell to the bottom of the tube ; when, on the 
contrary, the amount of blood was small, the urine being of a pale 
yellow colour, the precipitate, caused at the moment of boiling, 



COMPLICATIONS — ANATOMICAL LESIONS. 465 

merely gave an opaline tint to the fluid, and as the boiling was 
continued, furnished a delicate coagulum, which fell slowly to the 
bottom of the tube, The colour of the precipitate is said not to be 
of a pure white as in Bright's disease, but of a dirty brown or ash* 
gray tint. 

The author just quoted is of opinion that the anatomical lesions 
of the kidneys observed in fatal cases of scarlatinous dropsy, the 
characters of the urine, and the curability of the disease, all show 
that it is not dependent upon granular degeneration, or Bright's 
disease of the kidneys, but rather upon simple ordinary inflamma- 
tion, or even simple congestion of those organs. 

The degree of danger to be apprehended from this complication 
depends upon the form which it assumes. Cazenave (Loc. cit. p. 
52,) says that there is no danger from it so long as it remains con- 
fined to the subcutaneous cellular tissue, and this is probably true. 
When, however, it attacks the brain or lungs it becomes exceed- 
ingly dangerous. Dr. Wood (Pract. of Med. vol. i, p. 403,) says 
that he has seen but one fatal case from dropsy, and in that the heart 
was diseased. I have met with but two. It would seem to be 
much more dangerous in the Parisian hospitals than in private 
practice in this country, since Guersent and Blache speak of 
having saw it prove fatal in twelve, fourteen, and thirty-six hours, 
after one or two weeks, or even two or three months ; and Rilliet 
and Barthez refer to it as often proving fatal. 

Diarrhoea is not an uncommon accident of the disease. It 
generally depends on simple functional derangement of the bowels. 
In some cases, however, it is so severe or long-continued as to 
constitute a serious complication. Under these circumstances, it 
depends on follicular entero-colitis, slight erythematous inflamma- 
tion, or simple softening of the intestinal mucous membrane. 

Bronchitis and pneumonia are rare. Inflammation of the 
serous membranes is more common, occasioning in some cases 
the dropsical effusions which have already been treated of. Scarla- 
tina may be coincident with variola or measles. I have never 
seen it in connexion with the former, but in two cases which came 
under my observation it was complicated with measles. 

Anatomical lesions. — The eruption sometimes disappears en- 



466 SCARLET FEVER, 

tirely after death, and on other occasions assumes a deep livid or 
purple appearance. The epidermis is generally loosened upon the in- 
tegument, so as to be peeled off with great facility. The most im- 
portant lesions, and those which seem to belong to the nature of the 
disease independent of complications, are congestions of different 
parts of the body, particularly the brain, serous membranes, spleen, 
glands of Peyer, and intestinal follicles. It is a curious fact that, 
even when the cerebral symptoms have been most severe, and 
we might expect to find evidences of violent inflammation of the 
brain, nothing is observed after death, in the majority of cases, but 
congestion of the large veins and sinuses of the brain, of the pia 
mater, or of the cerebral substance. There is rarely any unnatural 
amount of serous effusion into the ventricles, or meshes of the pia 
mater. Dr. Tweedie says, " indeed, we have frequently been sur- 
prised, in examining rapidly fatal cases, to find no morbid appear- 
ances that could explain the cause of death." Nevertheless effu- 
sions within the cranium sometimes exist, as has been already 
stated in the remarks upon hydrocephalus. 

The respiratory organs are usually healthy, with the exception 
of congestion and serous engorgement. The abdominal viscera 
often present appearances analogous to those of typhoid fever. 
The glands of Brunner and Peyer are not unfrequently enlarged, 
and sometimes reddened or softened. In a smaller number of 
cases the mesenteric glands are slightly inflamed and increased in 
size, and the spleen redder than usual and softened. These lesions 
have no necessary relation to the form of the disease, since they 
are often absent in typhoid cases, and present in those of a different 
type. 

The kidneys are healthy, with the exception of some degree of 
congestion, unless the case has been complicated with dropsy. 
Under these circumstances they often present the characteristic 
lesions of Bright's disease. 

The blood presents very different appearances in different cases. 
It is viscid or serous, dark- coloured or light, and fluid or coagu- 
lated, the clots being of variable colour and density. The propor- 
tion of its constituent elements is changed. The .fi brine main- 
tains its usual relation to the mass of the fluid (3 parts in 1000), 



DIAGNOSIS. 467 

or is very slightly augmented, while the quantity of the globules 
is increased to 136 or 146, according to Andral, instead of 127 in 
1000 parts. 

Diagnosis. — It seems to me impossible to distinguish scarlatina 
from other febrile or eruptive fevers by the symptoms which pre- 
cede the eruption. The only signs upon which a diagnosis at 
that time might be grounded, are great frequency of pulse, which 
is characteristic of this disease, some soreness or redness of the 
fauces, and the prevalence of the disease in the community. But 
these are all exceedingly fallacious, and the physician should be 
content to wait for the eruption before he ventures to speak with 
certainty. After the eruption has come out it can scarcely be 
mistaken for anything else. 

From measles it may be distinguished by the differences in the 
prodromes, course, and eruptions of the two affections. The pro- 
dromic stage of scarlatina rarely lasts more than twenty-four 
hours, and is very often much less ; that of measles, on the con- 
trary, is almost always from three to four days ; in scarlatina the 
rash appears suddenly and is often completed in a single day; in 
measles it appears on the face first and extends gradually to the 
rest of the surface, seldom reaching the hands and feet before the 
end of the second day ; the eruption of measles occurs first in dis- 
tinct papulse, which coalesce and form patches of an irregular 
crescentic shape ; that of scarlatina is in the form of innumerable 
minute dots or punctuations, placed so closely together as to give 
to large portions of the surface an uniform colour, like that pro- 
duced by blushing. The colour of the two eruptions is different, 
that of measles being dark like raspberry juice, and that of scar- 
latina of a more or less bright scarlet tint. The presence of catar- 
rhal symptoms in measles and their absence in scarlet fever ; the 
absence of angina in the former disease, or its very slight charac- 
ter, and the severity of the throat-affection in scarlatina ; and 
lastly, the greater severity of the febrile symptoms, particularly 
the frequency of the pulse and heat of skin, in scarlatina, are 
other points of difference which will assist in making the diagnosis, 
rarely, it seems to me, difficult, more certain. 

From roseola it may be distinguished by the tint of the eruption, 



468 SCARLET FEVER. 

which is much brighter in roseola ; by the characters of the patches 
of eruption, which are more regular in shape, but of much smaller 
size in that affection ; and by the absence or very slight degree of 
sore-throat in roseola. Moreover, the latter disease is generally of 
shorter duration, is a milder affection, and therefore accompanied 
by far less fever and general disturbance of the constitution. 

Prognosis. — It is impossible to obtain a useful average mortality 
of scarlet fever, since the disease varies so greatly under different 
circumstances, that the results obtained during one period, are in- 
applicable to cases observed at another. This is proved by the 
experience of almost every physician, and by the evidence of many 
writers. It is proved, also, by the following facts. M. Gueretin 
(Loc. cit. p. 283) states that the mortality in the epidemic observed 
by him was about one in twelve : of 99 cases, 8 died. Rilliet and 
Barthez lost a little more than half their cases : of 87 the total, 46 
were fatal. These cases, let it be remarked, however, occurred in 
the hospital for children in Paris, which will account for the very 
great fatality. Of the 82 cases that I have seen, 13, or not quite 
a sixth, were fatal. 

The prognosis must be based therefore in part on the character 
of the epidemic prevailing at the time. It must depend also on 
the form of the disease. The regular and simple form is rarely 
fatal. Of 82 cases of the disease observed by myself, 73 belonged 
to this form, and of these not one was fatal. The grave form, 
on the contrary, is always exceedingly dangerous, and of the two 
classes of this form that I have made, the cerebral is much more 
so than the anginose. Of 9 cases of the latter kind, four died ; 
while of 10 of the cerebral form, all but one perished. It is clear, 
therefore, that the occurrence of severe cerebral symptoms early 
in the disease, is always of the worst augury. The character of 
these symptoms also should guide us in our prognosis. Excessive 
jactitation or irritability, delirium, coma, and the hydrocephalic 
cries, are all unfavourable symptoms, but not in the same degree 
as those connected with the locomotive apparatus. Rilliet and 
Barthez state that they have seen recoveries take place in cases in 
which the intelligence of the patient had been very much disor* 
dered, while of those who, " during the first fifteen days of scar* 



SYMPTOMS. 469 

lalina, were taken with convulsions, convulsive movements, con- 
tractions, in a word, any symptoms affecting the locomotive appa- 
ratus, all without exception, died." This does not accord exactly with 
my own experience. Of the 19 grave cases, convulsions occurred 
in seven in the " first fifteen days" of the disease, and in one on 
the twenty-fifth day. I am happy to be able to state, however, 
that contrary to the experience of the authors just quoted, two of 
the seven cases mentioned recovered. One of these occurred 
in a boy seven years old, who had a general convulsion, lasting 
several minutes, on the second day of the attack, which was fol- 
lowed by delirium and coma alternately, but no return of the con- 
vulsions. The case was a most violent one, and lasted six weeks, 
leaving the child at the termination very deaf, but otherwise in good 
health. The other instance occurred in a child five months old. 
The convulsive symptoms appeared on the ninth day, and consisted 
of strabismus, spasmodic retraction of the head, and occasional slight 
spasms of the limbs. They alternated with coma, and disappeared 
on the tenth day, until the seventeenth and eighteenth, when the 
strabismus reappeared. The child recovered perfectly. In ten 
cases, severe and prolonged delirium or coma occurred, and of 
these three recovered. We may conclude, therefore, that convul- 
sive symptoms in the early stage of the disease, indicate an almost 
certainly fatal termination; while severe or prolonged delirium 
and coma are also extremely unfavourable symptoms, but rather 
less so than those just mentioned. 

Other unfavourable symptoms are, extremely frequent or very 
violent pulse; intense heat or unnatural coolness of the skin; defi- 
ciency or sudden disappearance of the eruption ; a livid or purple 
tint of the eruption ; slow and imperfect capillary circulation, as- 
certained by pressure ; the appearance of petechia?, ecchymoses, 
or hemorrhages ; violent vomiting and colliquative diarrhoea ; great 
violence of the throat-affection, whether from tumefaction, great 
abundance of pseudo-membranous exudation, or disposition to ul- 
ceration and sloughing ; and lastly, severe coryza or otorrhoea. A 
disposition to typhoid symptoms, indicated by dulness of the in- 
telligence, dusky hue of the skin, frequent and feeble pulse, dry, 

40 



470 SCARLET FEVER. 

brown tongue, sordes on the teeth, meteorism, and disposition to 
diarrhoea, is always dangerous. 

When, on the contrary, the fever is moderate, the cerebral 
symptoms absent or very slight, and the eruption regular, and of a 
bright tint ; when there is no disposition to typhoid symptoms ; 
when the throat-affection is mild, and the disease pursues a regular, 
uniform course, we have every reason to expect a favourable ter- 
mination in a large majority of the cases. 

Treatment. — Hygienic treatment. — In all cases of the disease, 
whether of the regular or grave form, the strictest attention should 
be paid to the hygienic conditions of the patient. The room in 
which the child is placed ought to be, if possible, large, and at all 
events well ventilated. The temperature in winter should be care- 
fully attended to. I always direct it to be kept at from 68° to 70° 
F., unless the fever is violent, and the child complains of heat, in 
which case, it may be allowed to fall to 66°, but not often lower, 
in consequence of the great susceptibility to the influence of cold. 
The clothing ought to be moderate, not enough to increase the 
heat of skin and keep up constant perspiration, nor yet so little 
as to endanger chilliness. The diet should consist, in most of the 
cases, of weak milk and water, with or without bread, according 
to the severity of the case, and state of the stomach. If the 
fever be very severe, barley-water, or arrow-root prepared with 
water alone, may be given. Nothing more substantial than these 
articles ought to be permitted, in most cases, until after the patient 
is decidedly convalescent, when broth with rice boiled in it, or 
plain boiled rice, and then some light meat in small quantity, may 
be allowed, until the child gradually resumes its old habits. When, 
however, the case runs on for a length of time, or symptoms of 
prostration come on, light chicken or mutton water may be given 
at once, and small quantities of wine whey, or weak milk punch 
added, according to the degree of the symptoms. 

Treatment of the regular form. — In the great majority of cases, 
this form needs but very simple treatment. Some laxative, as 
magnesia, castor oil, or syrup of rhubarb, in such dose as to pro- 
duce two, or three stools, may commence the treatment ; or, if the 
general symptoms be rather more severe than usual, an emetic of 



TREATMENT. 471 

ipecacuanha had better precede the cathartic. After this, some 
diaphoretic should be given every two or four hours. If the skin 
is very hot and dry, I prefer the antimonial wine and sweet spts. 
of nitre, in the dose of two to four drops of the former, with eight 
or ten of the latter ; or a teaspoonful of neutral mixture, with a 
little nitre, or the spts. mindereri, may be substituted. At the 
same time a bath should be administered. This may be either a 
common bath at a moderate temperature (94° to 96°), or the affu- 
sion bath, given in the following manner. Prepare a bucketful of 
warm water (96° to 98°) containing from half a pint to a pint of 
vinegar ; undress the child, and place it standing in a large tub, 
with its head and shoulders slightly bent forwards ; then pour the 
vinegar and water from a pitcher over the body, letting it fall from 
a height of two or three feet, in a small, steady stream, on the 
nucha, so that it shall run over the whole surface, and fall into the 
tub. The moment the bath is finished, wrap the child in a warm 
blanket, which should be ready, and lay it in bed, or hold it on 
the lap, for twenty minutes, or longer if perspiration is induced, 
after which it is to be wiped dry and dressed. If the fever be vio- 
lent and accompanied with great dryness of the skin, two buckets- 
ful of water may be used. This bath is often followed by copious 
perspiration and sound, refreshing sleep, with great diminution of 
the heat and restlessness. It may be repeated twice or even oftener 
in the day. If the case be so mild as not to require an immersion 
bath, the pediluvium may be used with great benefit, as a sedative 
and diaphoretic. A moderate dose of some mild cathartic, or an 
enema, should be used from time to time, through the course of the 
disease, if the bowels are not moved spontaneously. This simple 
treatment will, I believe, carry the great majority of the cases of 
the regular form to a safe termination. Sometimes, however, even 
while the disease pursues a regular, uniform course, the general or 
local symptoms assume a degree of activity which renders more 
energetic treatment necessary. 

The febrile movement may be unusually active, and attended 
with so much restlessness, or by such an amount of delirium at 
night, as to threaten a change into the grave form of the malady. 
When this is the case, it is proper to resort to depletion, unless 



472 SCARLET FEVER. 

there be some strongly contra-indicating circumstances present. 
We may judge of the propriety of the measure by the constitution 
of the child, the state of the circulation, and the character of the 
eruption. If the child be not very delicate, if the pulse, be full 
and not excessively frequent, if the eruption be neither dark nor 
livid, showing a slow and languid capillary circulation, a venesec- 
tion of from three to six ounces may be safely and usefully prac- 
tised, and even repeated in twelve hours if necessary. In cases 
in which there has been unusual restlessness, with violent com- 
plaints of headache, in older children, without very great fever, I 
have resorted to applications of leeches to the temples with much 
benefit. At the same time a somewhat active cathartic may be 
given, [t is necessary to be careful in the use of purgatives ; for 
it must be improper and unsafe to give those which are irritating, 
or such doses of others as might prove so, in a disease which in 
its severe forms, shows a strong disposition to choleratic states of 
the bowels. I would rather, therefore, give a medium dose of a 
laxative remedy, and repeat it from time to time, than run the 
risk of exciting by a single over-dose, a condition of irritation 
which could scarcely fail to do mischief, by interfering with the 
regular course of the malady. For these reasons I generally re- 
sort to magnesia, followed by lemonade ; to castor oil in orange 
juice, in the dose of a dessert-spoonful for children over three years 
of age, and a teaspoonful under that age ; to simple syrup of 
rhubarb in the dose of a dessert or tablespoonful ; to a teaspoonful 
of salts ; or some similar remedy, giving directions that the dose 
shall be repeated in six hours, or assisted by an enema, if it fail 
to operate. At the same time the affusion bath as above directed, 
or the tepid immersion bath, ought to be used several times in the 
twenty-four hours, according to its effects, the temperature of the 
body, and the degree of restlessness. 

The angina needs no treatment whatever in a large majority of 
the cases. The physician should never, however, neglect to examine 
the fauces, when the case assumes any degree of severity. [^ 
under these circumstances, he finds evidences of severe inflam- 
mation of those parts, in the form of swelling, bright or deep 
redness, and still more, patches of whitish exudation, he may 



TREATMENT. 473 

fairly presume that this assists to occasion the unusual severity of 
the general symptoms, and should immediately apply remedies to 
check or modify the local disease. These may consist, under the 
restrictions already mentioned, of a moderate venesection, followed 
or not by an application of leeches to the throat ; or, if the local 
symptoms predominate over the general, or in very young children, 
of leeches alone. The number of leeches must depend of course 
upon the constitution and age of the child, and size of the leeches. 
I generally direct from two to three ounces of blood to be taken 
from a child two years old, and from three to five from those who 
are older. A great many different local remedies are recommended 
by different authorities. Those which I have made use of are the 
following: a solution of nitrate of silver (5 to 10 grs. to the ounce,) 
to be applied twice or three times a day; powdered alum used in the 
same way ; and a solution of sulphate of copper and quinine (6 
grains of each to an ounce of rose water), which has been very 
much used and greatly depended upon by my father, and which I 
have found very beneficial. This is to be applied in the same 
manner as the solution of nitrate of silver. With one of these I 
have always succeeded very well in this class of cases. Rilliet 
and Barthez recommend the following preparation : — R. — Acid, 
muriat. 3i, vel. ii ; Mel. Rosse 3i. — M. It is proper to avoid, under 
the circumstances above described, the use of caustic applications, 
as they are not needed, and as they might aggravate the local 
disease. 

Treatment of the grave form. — Bloodletting. — The propriety of 
bloodletting in the grave forms of the disease is questioned by 
many able observers, while others recommend it highly as an 
efficient means of controlling the dangerous symptoms. Guersent 
and Blache (Loc. cit. p. 177), state that in the ataxic malignant 
form " it is rarely useful to take blood, unless the general reaction 
is very acute ;" and in another place they say that in the adynamic 
typhoid form, bleeding has never seemed to them to be of any use. 
Dr. Burrows (Libr. Tract. Med. vol. i, p. 365,) states that Dr. 
Williams has drawn up a table of different epidemics of scarlet 
fever which have prevailed from 1763 to 1634. Dr. W. says, 
the conclusion which inevitably follows is, that the chances of 

40* 



474 SCARLET FEVER. 

recovery are diminished by the practice of bleeding, in the ratio 
of nearly four to one, as compared with the chances, supposing 
the patient not to have been bled." Dr. Burrows says, speaking 
of the anginose form, that in particular epidemics, or in some 
cases, bleeding may be required, but that in general the state of 
the circulation will not bear bleeding. Under the head of scarla- 
tina maligna, he says : " If bloodletting from the arm be a remedy 
of doubtful propriety in the former two varieties, it is here hazardous 
in the extreme. At the very onset of the disease the condition of 
the throat, or fierce delirium, may require the application of a few 
leeches beneath the jaw, or the abstraction of a few ounces of blood 
by cupping from the back of the neck." Dr. G. B. Wood, (Pract. 
of Med. vol. i, p. 406,) observes, that he has " seldom found it 
advisable to bleed in any case ; and I do not remember the instance 
in which it appears to me that I had occasion to repent my ab- 
stinence." Rilliet and Barthez recommend a bleeding in the early 
stage of the anginose form, to be followed by an application of 
leeches in robust but not in delicate children. In the malignant 
form with cerebral symptoms, they recommend a bleeding, if 
possible. M. Gueretin (Loc. cit. p. 301,) says, speaking of 
malignant cases, that the most energetic antiphlogistic treatment 
did not manifestly arrest the progress of the violent febrile pheno- 
mena, and that in robust subjects leeches to the neck and mastoid 
processes, did not sensibly ameliorate the cerebral congestion and 
delirium. Dr. Eberle follows Armstrong in recommending active 
bloodletting in the early period of the malignant form, but adds 
that it must only be during that period, " for the approach of col- 
lapse renders bloodletting utterly inadmissible." 

Trousseau and Pideux {Trait, de Therapeutique, t. i, p. 591, 
597,) strongly oppose bloodletting in scarlet fever, except in some 
very rare cases, in which there is " a state of general turgescence, 
cerebral congestion, painful tumefaction with stiffness of the ar- 
ticulations, rather elevated pulse, vomiting, imperfect generaliza- 
tion of the eruption." At page 596 are the following words, " of 
all the eruptive fevers, scarlatina supports antiphlogistic treatment 
least well." 

It ought to be recollected in the consideration of the propriety 



TREATMENT. 475 

of bloodletting, that the cerebral symptoms which make their ap- 
pearance in the early part of the disease, even during the first two 
weeks, are rarely dependent on inflammatory processes going on 
in the brain. This has been already shown in our remarks upon 
the cerebral symptoms. I will merely repeat here, that Rilliet and 
Barthez state, that a more or less active sanguine congestion is the 
only alteration generally, but not always, found in fatal cases, and 
that in some instances this congestion is not greater than what is met 
with in several diseases unaccompanied by cerebral symptoms. Are 
not these symptoms very analogous to those which occur in typhoid 
fever, and which, according to Louis, cannot be shown to depend 
on any appreciable lesion of the brain ? It seems to me most pro- 
bable that this class of symptoms is dependent upon the state of the 
blood, which, being diseased or poisoned, fails to carry on health- 
fully the functions of the nervous centres. If this supposition be 
correct, what good can arise from treatment which only takes 
from the circulating channels a small quantity of fluid, leaving 
behind a remainder just as irritating and unfit for carrying on the 
functions of the economy as that which has been removed ? 

On the whole, it is clear, I think, that the weight of evidence is 
against the use of bloodletting to any considerable extent in grave 
cases. If used at all, it is to be used only in the earliest period, 
and even then with great caution. My own opinion, derived from 
personal experience, is as follows : — I believe that I have seen 
general depletion useful in seven cases of the regular form, in which 
there was a tendency towards the grave form, shown by the pre- 
seace of excessive reaction, and still more by great jactitation and 
irritability, alternating with drowsiness and delirium. But, in those 
sudden attacks of the disease, in which it assumes from the very 
start, the terrible symptoms which threaten extreme danger to the 
patient ; in which we find the child, within a few hours of the onset 
delirious or comatose, or labouring under convulsions, convulsive 
movements or contractions ; in which the eruption is imperfect or 
scanty, or copious and of a deep livid tint ; in which, in other words, 
there are either strongly marked ataxic or adynamic symptoms, ge- 
neral bloodletting has never seemed to meat all advantageous, and I 
have several times feared that it had been injurious. As to leeches, 



476 SCARLET FEVER. 

I have never known them to be really useful except in one case, 
and in that they were used very sparingly, and after an interval of 
two days. In all the other cases they appeared to be without any 
effect. 

No depletion was employed in five of the nine cases of the 
grave anginose form that came under my observation, and of 
these two died and three recovered. Of the four remaining cases 
two were bled from the arm, of which one recovered and one died ; 
one was leeched upon the throat, and one on the temples, the for- 
mer of which proved fatal, the latter recovered. In one of the ten 
grave cerebral cases the treatment was not recorded. Of the re- 
maining nine, a single venesection was used in two ; in three, two 
venesections were employed, in one with the addition of leeches ; 
in one leeches were twice employed, once to the throat, and once to 
the temples ; and lastly, in three no depletion whatever was used. 
Of the nine cases, only one recovered, and that was the one in 
which leeches were employed alone on two different occasions. I 
will add that it has appeared to me that depletion in grave 
cerebral cases has very generally been followed by an increase of 
the nervous symptoms, by deeper coma, and by a more rapid ap- 
proach of the convulsive phenomena. Most assuredly, I have never 
seen it produce any of the evidently favourable effects which follow 
its employment in the phlegmasia, or in sudden determinations of 
blood to the brain. 

Purgatives ought to be used with care, and only in such doses 
as to secure a soluble state of the bowels, and never to cause vio- 
lent diarrhoea. M. Gueretin recommends, as the only treatment 
that he has found to be really useful in the malignant form, small 
doses of purgatives repeated two, three, or four times a day, so 
as to produce from two to four stools a day. If the stools be- 
came more frequent he suspended the purgative. This treatment 
was continued until the febrile symptoms had ceased. The remedy 
he preferred was calomel with jalap, in doses proportioned to the 
age of the child. This is the practice also of M. Bretonneau. 

Emetics are highly recommended by various writers in the early 
stage of the disease. Dr. Eberle (Dis. of Children, p. 461 ,) says, " If 
called sufficiently early, these should always be our first remedies." 



TREATMENT. 477 

I have prescribed them in several cases, and have certainly thought 
them useful in the regular form, but must confess that like all 
other remedies that I have used, they seemed to exert but little in- 
fluence over the grave forms. In young children, in whom large 
collections of viscid secretions in the fauces occasion difficult respi- 
ration, an emetic of ipecacuanha is often serviceable in mitigating 
that symptom. 

The antiseptic preparations of soda have been lauded by some 
persons as useful in the treatment of the malignant forms. I have 
not, however, met with any satisfactory evidence in its favour. I 
have only used it in two instances. One was a case of the grave 
pseudo-membranous form which lasted five weeks. The liq. sodse 
chlorinatse was given in the dose of five drops in a mucilaginous 
mixture every three hours for several days, without the least visible 
effect. This case proved fatal. The second was an instance of 
the same form. The same remedy was employed whilst the tongue 
was dry, cracked, and blackish in colour. Under its use the 
typhoid symptoms were slightly ameliorated, but not so rapidly as 
they afterwards were under the use of spirits of turpentine. The 
child recovered from this stage of the disease, but died on the 
twenty-sixth day of convulsions. 

Baths; lotions; affusions. — Of the various means that I have 
employed or seen employed in grave cases, these alone have seemed 
to me to exert a manifest influence upon the disease. The warm 
bath at 95° to 97°, continued for twenty minutes or half an hour, 
has always appeared to ameliorate for the time being the condi- 
tion of the patient. From being entirely comatose, the child has, 
while in the bath, awakened from its stupor and regained a slight 
degree of intelligence, so as to open its eyes, look round and 
drink freely. Unfortunately, the effect has always been transient, 
and though the heat of skin has remained rather less for some time 
after the immersion, the coma and disposition to convulsions have 
very soon returned. The same statements are made by M. Gue- 
retin, (Loc. cit. page 302.) I have also used the warm vinegar and 
water affusion, as described under the regular form, but without 
any more permanent effects. Sponging with tepid or warm water 
has usually been followed by marked diminution of the heat of the 



478 SCARLET FEVER. 

surface and of the frequency of the pulse ; but like the effects of 
all other remedies, the improvement has generally been temporary 
only, and the symptoms have soon resumed their previous violence. 

Lotions, by sponging with cool and sometimes cold water, are 
highly recommended by many authors. This plan is resorted to 
when the skin is intensely hot and dry, and is employed for 
several minutes until the heat is reduced, and the restlessness of 
the patient moderated. It must be repeated several times a day 
to be of any service. It is scarcely necessary to say that lotions 
are to be used only when reaction is strong and well-marked, and 
not when the skin is pale and cool, and the pulse rapid and feeble. 

We come now to the consideration of another method of treat- 
ment, which has been asserted to be most efficient in the violent 
forms of the disease by several persons of high authority in medi- 
cine, while by others it is considered dangerous and improper. I 
refer to the use of affusions with cold water. This treatment was 
particularly relied on by Dr. J. Currie of Edinburgh. Let it be 
observed, however, that Dr. Currie limits its use to cases, to 
which he applies the term anginose, many of which, I doubt not 
from his description, would now be included amongst the cases 
of the regular form. He mentions another class of cases which 
he thinks ought rather to be called " purpurata," characterized 
by " extreme feebleness and rapidity of the pulse, and great fetor 

of the breath The heat does not rise much above 

the standard of health. Great debility, oppression, headache, pain 
in the back, vomiting, and sometimes purging, accompany its 
rapid progress ; the patient sinks into the low delirium, and ex- 
pires on the second, third, or fourth day The 

cold affusion is scarcely applicable to it, and the tepid affu- 
sion makes little impression upon it. In my experience, indeed, 
all remedies have been equally unsuccessful. It outstrips in ra- 
pidity, and it equals in fatality, the purple confluent small-pox, to 
which it may be compared." (Currie* s Med. Reports, Philad. p. 
277.) It is clear, therefore, that Dr. Currie, when he speaks of 
nearly invariable success in upwards of one hundred and fifty 
cases (p. 286), had to do, not with the malignant, or at least, not 
with the most malignant forms, for which we are seeking a remedy, 



TREATMENT. 479 

but with cases of the regular form, or at most with those of the 
malignant anginose type. Indeed, at page 294, we find the fol- 
lowing remarks. " It has come to my knowledge, that in two 
cases of scarlatina, of the most malignant nature, the patients have 
been taken out of bed, under the low delirium, with the skin cool 
and moist, and the pulse scarcely perceptible. In this state, sup- 
ported by the attendants, several gallons of perfectly cold water 
were madly poured over them, on the supposed authority of this 
work ! I need scarcely add that the effects were almost imme- 
diately fatal." I have been induced to enter thus much into detail, 
in regard to the use of cold affusions, because of the intrinsic im- 
portance of the subject, and because of the remarks upon it in the 
work of Rilliet and Barthez, who bring forward Currie's success, 
as a strong argument in favour of their employment, in that 
form of the disease in which cerebral symptoms predominate. 
Currie does not recommend them, however, except in cases in 
which the reaction is full and strong, as indicated by very great 
heat of skin, scarlet eruption, and rapid, but not feeble pulse. In 
the famous cases of his own two children, it is evident that the 
attacks were not malignant, for the skin was very hot (108° and 
109° F.), and no mention is made either of stupor or delirium, 
much less of convulsive phenomena. 

The evidence brought forward by Currie, Gregory, and Rilliet 
and Barthez, in favour of the efficacy of cold affusions in the treat- 
ment of severe cases of the disease, is such, however, as ought to call 
attention to the point. It seems to me that they should be restricted 
to cases in which the reaction is perfectly well marked, in which the 
skin is hot and dry, the pulse though frequent (150 or 100) strong, 
and the eruption not of too dark a tint. The child is to be un- 
dressed, and placed erect or sitting in a tub, while four or five 
gallons of water, at from 60° to 70° F., are poured over the head 
and body. The good effects of the remedy are said to be an im- 
mediate reduction of the heat, a diminution of the rapidity of the 
pulse, which in one of Dr. Gregory's children fell in half an hour 
after the cold affusion from 160 to 120, a disposition to sleep and 
quiet, and, according to Dr. Gregory, a seeming arrest of the 
throat-affection. These good effects of the affusions are transient, 



480 SCARLET FEVER. 

however, as the heat of skin, and rapidity of the circulation, return 
in the course of one or two hours. For this reason it. is necessary 
to repeat them frequently, once in two or three hours at least, in 
order to render the effects permanent. Currie used fourteen affu- 
sions for one of his own children, and twelve for another, in thirty- 
two hours. These were not, however, all cold. Gregory used for 
his child five " good sousings," to use his own words, in twenty- 
four hours. 

Rilliet and Barthez give in the following words the conclusions of 
Henke in regard to the use of cold affusions : 1 . The cold affusions 
are not adapted for a general method of treatment. 2. The slight, 
or simply inflammatory forms, do not at all demand so energetic a 
treatment. 3. Their employment must be reserved for cases in 
which the disease is epidemic, and accompanied by intense heat 
and dryness of the skin, and by smallness and acceleration of the 
pulse, and for those in which the cerebral symptoms are very 
violent and characterized by great restlessness, alternating with 
drowsiness, commencing very early in the disease. Scarlet fever, 
under these circumstances, is so dangerous, and so often mortal, 
that recourse ought to be had to all curative means, and in children 
the cold affusions are much more strongly indicated than bleed- 
ing. (Loc. cit. vol. ii, p. 653.) 

Believing that evidence of the good effects of any plan of treat- 
ment in grave cases of scarlet fever, must be acceptable to all who 
feel an interest in the progress of medicine, I insert at this place 
an account of the employment and effects of cold lotions, by Dr. 
Hiram Corson, of Conshohocken, Montgomery county, Pennsyl- 
vania. The cases narrated occurred in his own practice, and were 
kindly communicated by letter, at my request. Dr. Corson writes 
to me in July, 1847 : 

" Dear Doctor, 

" Scarlet fever is a disease that has prevailed very much in 
our region during the last seventeen years, and has caused me 
much thought and anxiety. It will give me great pleasure to 
make you acquainted with the results of a plan of treatment, which 
I owe mainly to Doctor Samuel Jackson, formerly of Northum- 



TREATMENT. 481 

berland, now of your city, who first put me in the way of treating 
the disease successfully. In 1833, I treated the disease, which, 
however, was not malignant, very successfully, with iced drinks, 
moderate purges, and slight irritation externally upon the throat, 
and thought the practice peculiar to myself, but afterwards saw 
in the May and August numbers of the Am. Journ. of Med. 
Sciences, the communications of Dr. Jackson. Encouraged by 
these, I prepared to try the cold externally, when a most unfortu- 
nate trial, by a neighbouring physician, so alarmed the people 
about the application of cold, that I could not prevail upon them to 
suffer the trial. From 1838, until within the last two years, we 
have annually had the scarlet fever for some months, and my 
treatment, with the exception of iced drinks sometimes, and cold 
to the head occasionally, was like that in general use, until Au- 
gust, 1844. At that time I was called to a child eight months old, 
who had been sick two days. There was great swelling of the 
glands of both sides of the neck, hot skin, frequent pulse, but no 
eruption ; slight discharge from the nose ; the glands not easily 
seen upon the inside, but the drinks came back through the nose 
sometimes, and it could not take more than one draw at the breast, 
without dropping the nipple, because of the obstruction in the nos- 
trils impeding respiration when the mouth Was closed. I stated 
candidly to the mother that I had never saved a child in that con- 
dition, and of that age, by the old treatment, and recommended ice 
externally and internally, cold water to the head, and no medicine. 
I could urge nothing upon the score of experience, but she agreed. 
Lumps of ice were folded in linen cloths and held night and day 
upon the two sides of the throat ; while a small thin piece enclosed 
in white gauze was held in the mouth. In less than three hours 
improvement was manifest in the ability to swallow. The swell- 
ing of the glands, the heat, and the frequency of the pulse all 
regularly diminished, and in two days the child could nurse well 
and was out of danger. 

" The next severe case occurred in about two weeks. It was one 
of the most intense scarlet eruption, with tumefaction and ulcera- 
tion of the tonsils, vomiting, coryza, great frequency of the pulse, 
excessive restlessness, and swelling of the external glands. The 

41 



482 SCARLET FEVER. 

heat was intense ; there was heaviness amounting almost to stupor. 
My treatment was a kind of half and half: emetics, purgatives, 
cold externally and internally. Being but half satisfied with my- 
self, my course was vacillating and inefficient, and I at length 
called in a friend, who turned the scale in favour of irritating 
gargles, and our patient died. I was mortified and provoked, and 
determined to act out my convictions at the next opportunity. A 
few days after I was called to two boys of five and seven years of 
age, who had been blistered upon the throat, legs and arms, and 
had had hot drinks, calomel purges, etc., etc., and who were dis- 
charging copiously from the nose, and were almost deaf. Their 
countenances were sunken, the throats gangrenous, pulse above 
150; their appearance was that of persons in typhus fever. I 
expressed my fears of the blisters, predicting that they would all be 
gangrenous in twenty-four hours, and that they would be likely to 
destroy the patients. I had cloths dipped in iced water wrapped 
round the neck, ice was put into the mouth, and cold water 
poured upon the heads, which were much affected. The throats 
were filled with ropy mucus, which was expelled through the 
mouth and nose during the coughing which attended efforts to 
vomit. The palate was literally destroyed by gangrene. A few 
hours produced an amendment. The blisters mortified extensively, 
and though both children recovered from the disease, one died 
two weeks afterwards from the sloughing of the throat and neck 
from the blisters. 

" I now treated all the cases that occurred with cold externally 
and internally ; moving the bowels with equal parts of cream 
of tartar and jalap. The cases were seen early and easily 
subdued, and it seemed to me as though the remedy was very 
efficient, or that my patients had a mild disease. That the latter 
was not the case, however, I thought probable from the fact that 
in my region, many cases differently treated died ; while in Nor- 
ristown, only four miles distant, children from one to twelve years 
or more, were swept off after an illness of only two or three days, 
the deaths being evidently produced by disease of the brain. 

"On the 16th July, 1845, I was called to see a little girl four 
years and nine months old. She had been sick a day or two. 



TREATMENT. 483 

The case began with vomiting. The eruption has been out since 
morning (now, 6 p. m.) ; redness the most intense all over that 1 
ever saw ; pulse as rapid as it could be to be counted. The mo- 
ther had been alarmed during the last few hours, in consequence 
of delirium and jerking, which she feared was the prelude to con- 
vulsions. There was tumefaction of the sub-maxillary ganglions; 
tongue furred, with projecting red points ; breath hot and offensive. 
When she found some one holding her wrist, she started from her 
dozing state, and being somewhat afraid of the ' doctor,' went off 
immediately into one of the most terrific convulsions that I ever 
saw. It lasted, in spite of ice to the head, or rather iced water 
constantly poured upon it, almost half an hour. I stayed with her, 
had her undressed, and placed two nieces of mine (her mother 
being one) by her side. A large tub of water with cakes of ice, 
at least a peck, floating in it, was brought into the room, and dur- 
ing the whole night, these two persons bathed her from head to 
foot with the water from this tub, applying it by means of large 
sponges. It was to me a most painful case (independent of the 
convulsions), but in order to be certain that I had a case fit for a 
trial of the ice, I had my brother (a physician practising at Nor- 
ristown, where the disease was very fatal) brought at 10 p. m., to 
see the case, and to say whether it was the same as those that had 
for a few weeks been carrying off some of the finest children in 
Norristown, and carrying terror into every family. He assured 
me that it was one of the most violent character, and that she 
would in all probability not live till morning. She was at this 
time free from convulsions, but in a muttering delirium. As I 
had perfect control in the case, I assured him that she should live 
if I could quench the fire that was burning out her vitals, by the 
use of ice. Not a moment did the attendants whom I had placed 
by her intermit their labours. Before midnight reason had return- 
ed, and her mother said she was more herself than she had been 
during the whole day. I had gone away, but returned at sunrise, 
and found her cooled off perfectly. There was scarcely the least 
appearance of eruption, the skin was cool, the head cool, the intel- 
lect clear, and the pulse moderate in frequency and force. She 
had been unable to drink for many hours, and her tongue, which 



484 SCARLET FEVER. 

had been very much cut during the convulsion, was so swelled 
and sore, that I could obtain no view of the throat. I now directed 
the mother to intermit the sponging, doing it only once in every 
two hours, until I returned. My return was delayed until 4 p. m., 
when I found that the heat of skin, frequency of pulse, eruption, 
and delirium had all returned. She was moving her hands as 
if feeling for something, slowly protruding and withdrawing the 
tongue, and muttering. She did not notice her mother's questions, 
and was apparently unconscious to all that was going on. We 
threw on the water, ice-cold, in the utmost profusion, and lapped 
cloths dipped in the water around the neck, changing them every 
minute or two. We poured it upon the head constantly, holding a 
large basin under to catch it. In one hour, reason returned. We 
continued it until the eruption almost disappeared, until the child 
shrank from it, and until she was ready to shiver with cold. I 
now gave her cream of tartar and jalap, directed the water to be 
used just as was needed to keep down the heat, and had no farther 
trouble with her. I forgot to say that so soon as she could swal- 
low, cold drinks and ice were kept in the mouth. She took no 
more medicine. The wounds in the tongue healed up kindly. 

" There were two younger children in the family, both of whom 
were attacked a few days after, while apparently in good health, 
with vomiting and the same symptoms as in the first case. The 
throats were red and swelled, etc. Cold cloths were wrapped 
around the neck ; they were purged with jalap and cream of 
tartar ; as the heat of skin and eruption appeared, ice water was 
profusely applied to the whole body, so as to keep down the heat, 
and allow but a very moderate eruption to show itself. They were 
well in a few days without a bad symptom. It was now mid- 
winter. The cases followed each other rapidly. I treated them 
all in the same way, and all with like happy results. The dis- 
ease had a wide range, extending from the Schuylkill across the 
highlands between Norristown and Doylestown, and was in that 
range very destructive in many families. There was much alarm, 
and I was called two miles back of Norristown to a girl about 
eleven years old. The eruption had been out about twenty-four 
hours. The throat was swelled and covered with white patches 



TREATMENT. 485 

(generally called ulcers) ; tongue dry, hot, and red ; skin hot as 
skin could be ; and, what to me characterizes the most malignant 
cases, the eruption instead of being of a bright scarlet, was of a 
purple red, like the congestion sometimes seen in the faces of old 
drunkards. There was great oppression, not difficulty of breath- 
ing, but a state like that which exists when a person is deathly 
sick but cannot vomit ; with extreme restlessness and jactitation. 
The disease had been so fatal, that the mother thought the case 
almost beyond remedy, but when I told her that the cold had 
proved successful, she was eager to try it. It was 8 o'clock, a.m. 
The girl was stripped, and the iced water applied all over. Ice 
was lapped around the neck, and positive directions given to con- 
tinue the applications without intermission until I returned. It 
was about four miles from me, and I did not return for seven 
hours. The moment my eyes rested upon her, I knew that we 
had done too much. She was white as the sheet upon which she 
lay. The neighbours had been in and desired the mother to desist, 
that ' she would kill her,' but she had been true to her trust. The 
child was apparently bloodless, covered with ' goose-skin,' and 
shivering with cold. Her pulse was small and much less frequent, 
but not weak or fluttering, and she was sensible. (I forgot to say 
that in the morning she was quite flighty.) I told the mother we 
had used rather more cold than was necessary, but that if we left 
it off now, she would probably do well. I omitted it for two hours, 
and gave nothing. At the expiration of that time, the heat, and 
with it the eruption, showed themselves, so as to cause me to direct 
: the sponging to be used just so as to keep them in check. The 
ice was kept constantly to the neck, and water frequently poured 
over the neck. I had no more trouble with her, although she 
desquamated from head to foot. 

Six other children in the family took the disease. Five of them 
had the ice and ice water used upon them, and all did well. I 
gave none of them any medicine except a little cream of tartar 
and jalap, to move the bowels moderately. I gave this combina- 
tion because it is pleasant to children, and easily swallowed. The 
sixth case was a very mild one, so that the mother merely gave it 
a little castor oil, and it did well, and seemed perfectly recovered 

41* 



486 



SCARLET FEVER. 



in a few days. Indeed the attack was so mild, that it would not 
have been detected as scarlet fever, if it had occurred at any other 
time. It was attacked with dropsy and an affection of the lungs, 
about two weeks after, lingered for several weeks, and finally died 
of pneumonic disease. 

" I suppose I have attended more than a hundred cases of scarlet 
fever of every grade, since I began the cold treatment. In no in- 
stance where I had it fairly applied did it fail. Indeed I have lost 
but two patients since. 

" In every variety of sore throat and quinsy, in summer and in 
winter, my treatment is ice around the neck ; or, when the nurse 
is faithful, iced cloths, renewed as soon as they approach the heat 
of the neck. 

" In no single instance have I seen dropsy follow scarlet fever 
that had been treated by cold affusion. I have never seen it occur 
except after the mildest cases of the disease, those that had probably 
only needed a mild laxative." 



I will now make a short statement of my own experience in the 
external use of cold. I have never employed the cold affusion 
over the whole body, and never saw it employed but once. In that 
instance a single bucket-full of water at 70° was poured over the 
child, but as it was not repeated, no good effects, beyond a very 
transient reduction of the heat, and quiet for a short time, were 
produced. In another instance I made repeated affusions upon the 
head with water at 70°, pouring at one time seven buckets-full 
upon that part. This was a case attended with coma, strabismus, 
and spasmodic retraction of the head. In addition to the affusions, 
cloths dipped into iced water were kept applied the greater part of 
the time. These means, especially the affusions, were evidently 
advantageous, and the child recovered. 

Since receiving the above letter, I have resorted to lotions with 
cool water, (70°,) in two cases of the grave anginose form, and in 
both with benefit. In one of them particularly, its effects were 
immediately and evidently advantageous. The case occurred in 
a hearty, vigorous girl, twelve years of age. On the third day of 
the attack, the symptoms were as follows. The pulse was between 
160 and 170, small and quick ; skin intensely hot ; eruption very 



TREATMENT. 487 

copious, and of a deep dark red colour, tending to violet ; capillary 
circulation slow and languid ; tongue black, and covered with a 
hard dry crust ; teeth and lips dry and covered with dark incrus- 
tations. There was very great agitation and restlessness, with 
constant moaning and complaining, and total insomnia. Under 
these circumstances, I directed the nurse to sponge the head and' 
extremities of the patient with water of the temperature of the 
room (68° to 70°). As the water became heated by contact with 
the skin, small pieces of ice were put into the basin so as to keep 
the temperature at the degree mentioned. At the end of four 
hours, the washing having been continued all the time, I found the 
patient decidedly more comfortable. The pulse had fallen to 140, 
and increased in volume ; the heat of skin was much reduced ; 
the colour of the eruption had improved, having become much 
more scarlet in tint ; the capillary circulation was more active ; 
the agitation and restlessness had very much moderated, and the 
child had slept somewhat at short intervals. This treatment, in 
conjunction with the internal administration of the solution of 
chlorinated soda, and small doses of spirits of turpentine, was 
continued for several days, the sponging being used whenever 
the heat and restlessness were great, and the pulse very rapid. 
The child convalesced about the end of the third week, but was 
unfortunately seized with symptoms of hydrocephalus on the 
twenty-fifth day, and died in twenty-three hours, after the most 
frightful convulsions I ever saw. 

o 

Tonics and stimulants. — Whenever in the course of scarlet 
fever, the low typhoid symptoms we have described, make their 
appearance, it is necessary to resort to tonics and stimulants. 
This condition I have never seen occur but once in the acute 
cerebral form, which lasts only a few days. That was in a case 
the onset of which was like that of violent cholera morbus. It is 
in the slow and tedious cases of both the grave anginose and 
cerebral form, and not unfrequently in the early period of the 
former, that adynamic symptoms generally occur. The pulse 
becomes frequent and small ; the skin cool and moist, or hot and 
cold by turns ; the tongue is dry and cracked ; there is sordcs 
upon the teeth ; and there is great jactitation, muttering delirium, 



488 SCARLET FEVER. 

and various nervous symptoms, which all clearly indicate great 
exhaustion of the vital powers. Under these circumstances it is 
proper to resort to whatever means are likely to uphold the con- 
stitution, and impart to it strength to resist the slow disease that 
tends to destroy it. With this view the diet ought to consist of milk 
preparations, and of light animal broths, with bread, if the child 
will take them. At the same time wine whey in proper doses, and 
at fixed periods, ought to be given ; — or the whey may be mixed 
with arrowroot water; — or wine may be given in simple cold water. 
If the prostration be very great, small quantities of brandy may 
be used. We may resort also to the internal use of quinine, in 
the dose of a grain three or four times a day, to a child two or 
three years old, or to the cold infusion of bark. The aromatic 
spirits of hartshorn is useful in doses of ten or fifteen drops every 
two or three hours ; or the carbonate of ammonia in emulsion ; or 
the infusion of serpentaria, which is highly spoken of by some of 
the German authors. For my own part, I rely chiefly on diet, 
wine and brandy, and quinine. This treatment should be con- 
tinued as long as the adynamic symptoms last. I believe, how- 
ever, that I saw good effects obtained recently in one case, from the 
use of the chlorinated soda according to the following formula : — 
R. — Liqu. Soda? ehlorinat. gtts. xl ; Syrup Tolutani 3i ; Aquas 
font. 3iii. — M. Give a tablespoonful every three hours to a child 
from eight to twelve years old. I afterwards employed in the 
same case, on account of the occurrence of a considerable and 
painful degree of meteorism, small doses, three drops every three 
hours, of spirits of turpentine. 

Treatment of the Angina. — The pharyngeal inflammation re- 
quires a chief share of our attention in the grave anginose variety 
of the disease. 

It is scarcely necessary, after the previous remarks on blood- 
letting, to say much in regard to its employment in combating this 
element of the malady. It may be used with great caution in the very 
earliest stages, while the reaction is still full and strong. I prefer 
leeches to bleeding, and believe that about four ounces are as 
much as ought generally to be taken from a child three or four 
years old. 



TREATMENT. 489 

When the external swelling is considerable, benefit is sometimes 
derived, I think from the steady application of warm poultices to 
the part. They should be enclosed in portions of thin soft flannel, 
and secured by means of a very light cravat. They ought to be re- 
newed every two or three hours. The reader's attention is called to 
the use of cold applications to the throat as recommended by Dr. 
Corson, in the letter appended to my remarks on baths and lotions. 
j A great variety of local remedies have been proposed by different 
authorities. Amongst the best are powdered alum, and solu- 
tions of nitrate of silver and sulphate of copper or zinc. Cauteri- 
zation of the throat, with the view of arresting the formation of 
the exudation, so useful and important in primary pseudo-mem- 
branous pharyngitis, seems to be of doubtful propriety in this 
disease. Gueretin (Loc. cit. p. 300), is of opinion that cauteriza- 
tion increases the phlogosis, augments the tumefaction of the gan- 
glions, and aggravates the fetidity of the breath. Cazenave, on 
the contrary, (Abreg. Prat, des Mai de la Peau, p. 56,) advises 
the early touching of the diphtheritic patches with muriatic acid or 
nitrate of silver, in order to modify the peculiar inflammation. 
He also states that M. Biett habitually employed a mixture of 
equal parts of lemon juice and honey. Rilliet and Barthez recom- 
mend an application consisting of equal parts of honey of roses 
and muriatic acid. Cayenne pepper in infusion or substance 
has been recommended by different authors. Dr. G. B. Wood, 
(Loc. cit. vol. i, p. 408,) thinks that it exercises a peculiar and 
very happy influence " when the pseudo-membranous or gan- 
grenous patches are observed in the fauces, and when the colour 
of the mucous membrane is dark red." He mixes the powder in 
water, and applies it to the fauces by means of a large camel's 
hair pencil. When the breath is very fetid, the liq. sodse chlorinatse, 
diluted with eight to ten parts of wat^r, is said to be very ser- 
viceable. I have usually preferred the solution of nitrate of silver, 
or that of sulphate of copper and quinine, both of which have 
already been mentioned. 

In the use of any of these preparations in children, it is necessary 
to apply them to the fauces in the manner described in the article 
on idiopathic pseudo-membranous pharyngitis. When viscous 



490 SCARLET FEVER. 

secretions collect in the fauces in such quantity as to cause serious 
annoyance to the child, and embarrass the respiration, they ought 
to be removed by means of a sponge mop, or camel's hair brush. 
When coryza is present, the nostrils should also be cleansed 
from time to time with a small brush, and then freely anointed 
with sweet oil, or some mild ointment, or they may be touched 
with the wash used for the throat. To perform these little offices 
for the child, almost always requires force, but they are followed 
by such comparative ease and comfort, and I doubt not, mitiga- 
tion of the disease, that they ought to be insisted upon. 

For the otorrhoza which sometimes occurs, it is seldom necessary 
to do more during the violence of the attack, than to cleanse the 
ears twice or three times a day, by syringing with warm water and 
castile soap, or with a weak solution of alum. After the violence 
of the attack has subsided, this complication should be treated as in 
idiopathic cases. 

Treatment of the dropsy. — In mild cases the only treatment ne- 
cessary is the use of some mild purgative, as castor oil magnesia 
or a small dose of calomel, warm baths when the fever is con- 
siderable, minute doses of antimony and sweet spirits of nitre, a 
simple diaphoretic, as cream of tartar lemonade with sweet spirits 
of nitre, carefully regulated diet, and strict confinement to bed. 

In more severe cases, when the fever is violent, or when the 
disease attacks some of the cavities, and particularly when con- 
vulsions, coma, or violent delirium occur, indicating inflammation 
of the membranes or cavities of the brain, resort must be had to 
depletion. The mode of depletion must depend on the nature of 
the case and the present condition and constitution of the patient. 
If possible, venesection is to be preferred, and when that cannot be 
borne, cups or leeches may be substituted. Active doses of cathar- 
tics ought to be given immediately after depletion, and if the symp- 
toms are very urgent, enemata may be employed to hasten their ope- 
ration. Warm baths are of great service in the treatment of this com- 
plication. They promote diaphoresis, and thus moderate the febrile 
movement, and assist in removing the effusion. After these reme : 
dies, or in conjunction with them, diuretics are to be chiefly relied 
on. The best is probably digitalis, which may be used either in 
powder or infusion ; I would prefer to give it in combination with 



TREATMENT. 491 

the acetum scillse, as recommended under the head of pleurisy. If 
given in infusion, a teaspoonful of the officinal preparation may be 
directed for a child four years old, to be repeated every four or six 
hours, carefully watching its effects. Calomel is highly recom- 
mended by many writers, and would no doubt be useful in con- 
nexion with the other treatment. 

Prophylactic treatment. — It has been asserted that the use of 
' belladonna by persons exposed to the contagion of the disease, has 
the power of imparting perfect or nearly perfect immunity from its 
attacks. Not having had the slightest experience in regard to this 
matter, I can offer no opinion of my own upon it. From the evi- 
dence brought forward in the European works that I have seen, its 
efficacy seems to me to be left in considerable doubt. Rilliet and 
Barthez areofopinionthatitis at least worthy of trial. Cazenave(ioc. 
cit. p. 58,) states that " M. Biett saw the disease reign epidemically in 
one of the lofty valleys of Switzerland, and respect, almost with- 
out exception, children to whom the belladonna had been ad- 
ministered." Guersent and Blache (Loc. cit. p. 180,) after citing 
various accounts of its use, conclude that " these trials ought, un- 
doubtedly, to be continued." According to Dr. Condie (Loc. cit. 
pp. 441, 442,) Dr. Irwin made an extensive trial of its prophylactic 
powers in South Carolina, and found that of two hundred and fifty 
children who took it, less than half a dozen had the disease, and 
that very mildly. Dr. McKee, in an extension of the same epide- 
mic, used it with like success. 

Dr. Condie himself made use of it, " but although redness and dry- 
ness of the throat, and a diffuse scarlet efflorescence were produced 
in the majority of the cases, we never found it in any, to exert the 
slightest influence in mitigating the character, or preventing the 
occurrence of scarlatina. The experiments were made during the 
prevalence of the disease, and in numerous instances, the subjects 
of them were attacked. In one case, the efflorescence was kept up 
by the use of belladonna, for forty-eight hours ; in a week after- 
wards, this individual took the disease, in its most violent form, 
and died on the fourth day." 

Dr. Irwin gave it in the following manner. Three grains of the 
extract were dissolved in an ounce of cinnamon water, and two or 



492 MEASLES. 

three drops of the solution given morning and evening, to a child 
under one year old, and one drop more for every year above that 
age. 

Hufeland's formula is as follows, according to Rilliet and Barthez : 
— R. Extract. Belladonnee gr.. iii ; Alcohol 3j ; Aquse Distillat 
3ss. A drop morning and evening for each year of the age of 
the child. 



ARTICLE II. 

MEASLES, RUBEOLA OR MORBILLI. 

Definition ; frequency ; forms. — Measles are an epidemic and 
contagious exantheme, characterized by catarrhal symptoms, con- 
tinued fever, and an eruption, generally on the fourth day, of a 
crimson rash, in the form of stigmatized dots, like flea-bites, slightly 
elevated, which coalesce into irregular circles or crescents. It 
ends about the seventh day by desquamation. 

The frequency of the disease is very irregular in different years 
because of its epidemic nature. Thus, according to the tables of 
Dr. Emerson (Loc. cit.), the mortality from measles under twenty 
years of age, in the twenty years from 1807 to 1827, was 654. In 
seven of these years, (1807, 1809, 1813, 1817, 1818, 1821, 1822), 
not a death is recorded ; in five, the deaths varied between one and 
eight for each ; while in the remaining years, they were as fol- 
lows : 20 in 1812 ; 38 in 1825 ; 47 in 1820 ; 71 in 1808 ; 98 in 
1826; 99 in 1824; 106 in 1819 ; and 155 in 1823. During the 
same period, the deaths from scarlet fever were, as has been 
already stated, only 93, which shows a great preponderance of 
measles. If, however, these results are compared with those given 
by Dr. Condie, for the ten years preceding 1845, it will be found 
that scarlatina was far more fatal during that period than measles ; 
for whilst the deaths under 15 years of age from the former 
numbered 2154, those from the latter were only 574. 

I shall describe two forms of the disease ; the regular or rubeola 



CAUSES SYMPTOMS. 493 

vulgaris ; and the malignant or rubeola maligna. I shall after- 
wards treat of its irregularities and complications. 

Causes. — A chief cause of the disease is its epidemic nature. 
Of this there can be no doubt, as it is proved by the evidence of all 
observers. 

Contagion. — Its infectious nature is universally admitted. This 
is thought to begin with the primary fever, and to continue up to 
the period of desquamation. The precise period at which it ceases 
is not however known. The disease may be carried in fomites. 
It has been propagated also by inoculation, with the blood taken 
from a patient, and with serum obtained from the vesicles which 
sometimes accompany the eruption. 

The period of incubation is from five or six, to twenty days or 
even longer. The average duration is about a week or ten days. 
In the inoculated cases the disease appeared about the sixth or 
seventh days. 

Rilliet and Barthez conclude that measles are more frequent, 
less contagious, and have longer stages of incubation and of pro- 
dromes than scarlet fever. 

The same authors are of opinion that variola is somewhat more 
rare, rather more contagious, and that its period of incubation and 
its prodromic stage are a little shorter than those of measles. 

Measles, like other contagious diseases, rarely occur a second 
time in the same individual. 

Age. — It appears from the tables of Emerson and Condie, that 
they are most frequent between the ages of 1 and 2 years, for 
while they report 3 ( J5 deaths in that period, there were but 468 
between 2 and 5 years. According to my personal experience, it 
is most frequent in the second, third, and fourth, and then in the 
sixth and seventh years of life. The largest number of cases oc- 
curred in the second, sixth, and seventh years. 

Sex. — It would appear to attack the two sexes with about equal 
frequency. Of 135 cases that I have seen, in which the sex was 
noted, 65 occurred in females, and 70 in males. 

Symptoms ; course ; duration. — Regular form of the disease. — 
Stage of invasion. — Measles begin with languor, irritability, some- 
times chilliness, anorexia, aching in the back and limbs, fever, 

42 



494 MEASLES. 

thirst, headache, and various signs of irritation of the mucous 
membrane of the eyes, nose, fauces, and larynx. 

The chilliness or horripilations which are mentioned by almost 
all writers, are difficult to appreciate in children. I have seldom 
known the child itself to complain of them, but upon inquiry of the 
mother or nurse, have sometimes been told that they had observed 
some coolness of the hands or feet, or a disposition to keep near 
the fire, and a desire for additional clothing. These, therefore, are 
not important symptoms. Neither is the aching in the back and 
limbs, as it is seldom complained of by children, and can be ascer- 
tained in those who are older only by close questioning, or sus- 
pected in the younger by their complaining when they are moved. 
Fever is very rarely absent. It almost always comes on with, or 
very soon after the other prodromes, but in rare cases does not 
begin until the second day. It is almost invariably continued, after 
it once begins, except that it remits somewhat about daylight and in 
the early part of the morning, to become exacerbated again in the 
after part of the day. Its intensity increases, and the remissions 
become less distinct and shorter, as the time for the appearance of 
the eruption approaches. The pulse is increased in frequency, 
force, and volume, but rarely attains the same ratio that it does in 
scarlet fever. At the same time the skin becomes warm and dry, 
the face is generally flushed, and there is considerable restlessness 
and irritability at first, often passing into quiet and drowsiness as 
the eruptive point approaches. The fever is accompanied by thirst, 
partial or complete anorexia, and generally by headache, which is 
frontal, and often complained of by children old enough to give an 
account of their sensations. Vomiting occurs sometimes, but not 
as a general rule. The catarrhal symptoms commence with, or 
may even precede the fever. They constitute the most character- 
istic symptoms of the disease, and indeed the only ones by which 
we are able to distinguish it with any certainty in the first stage. 
They are irritation and redness of the conjunctiva, especially that 
of the eyelids, lachrymation, suffusion of the eyes, sensibility to 
light, stuffing of the nose, coryza, sneezing, slight soreness of the 
throat, cough, some constriction of the thorax, and slight dyspnoea. 
The state of the eyes and nose are very important as signs of the 



SYMPTOMS. 495 

disease. They are not always present in the same degree, being 
very strongly marked in some instances, in others less so, and in 
some rare cases, absent. They are important because there are 
few cases of ordinary cold in which they are present to the same 
extent, or if so, the accompanying general symptoms are slight 
compared with those of measles. I have rarely known the 
faucial affection severe enough to elicit complaints, and never to 
produce difficulty of deglutition. It consists generally only of slight 
redness of the tonsils, soft palate, and pharynx, which is most 
strongly marked about the time that the eruption makes its appear- 
ance. The cough usually appears on the first day. Infrequent 
and slight at first, it becomes more troublesome as the case pro- 
gresses, until it assumes on the third or fourth day a character 
which is peculiar, and which may often lead to a suspicion as to 
the true nature of the attack. It is laryngeal, hard, dry, rather 
hoarse, and occurs generally in short paroxysms. At the same 
time the voice is often hoarse. The tongue is usually white and 
somewhat furred ; the bowels remain in their natural condition, or 
there may be slight constipation or diarrhoea. Constipation is 
most frequent, according to my own experience. The drowsiness, 
to which we have already alluded, often exists during the first 
stage. I have noticed it in a great many cases. The child, if 
undisturbed, sleeps quietly for many hours, or for the greater part 
of one or two days, waking only from time to time to ask for 
drink, and then sinking off to sleep again. The symptom is not 
alarming, unless it be connected with others which indicate local 
disease, or unless it passes into coma, or alternates with violent 
delirium. Other nervous symptoms which sometimes occur, espe- 
cially when the fever is violent, are restlessness, irritability, occa- 
sional delirium at night, and in very rare cases, convulsions. Of 
167 cases observed by Rilliet and Barthez, the latter symptom ap- 
peared in the first stage only in one, and was then confined to the eye- 
balls. I have met with it twice in 137 cases. In one it occurred 
on the first day in a boy five years of age, of nervous tempera- 
ment, and who had had several convulsive attacks during the process 
of dentition. The convulsions were general but slight, lasted only 
a short time, and were not followed by any bad consequences. In 



496 MEASLES. 

the other case the sickness began with fever, drowsiness, tremu- 
lous movements of the hands, delirium, and in a few hours a slight 
general convulsion. On the second day there were two attacks 
of convulsions, both, however, slight. The other symptoms con- 
tinued as before. On the third day the child was better, the fever 
having diminished, and the nervous symptoms in great measure 
disappeared. On the fourth, fifth, and sixth days, the fever re- 
turned, and on the middle of the sixth day, a full measles rash 
made its appearance. There was no recurrence of the nervous 
symptoms, and the case ended favourably. MM. Guersent and 
Blache (Diet, cle Med. t. 27, p. 658), mention another prodromic 
symptom, which has sometimes enabled them to recognise the 
approach of measles before the eruption. This is a peculiar red- 
ness, a rose-coloured punctuation, of the roof of the mouth, soft 
palate and uvula, differing from that of scarlatina. 

The duration of the prodromic stage is generally from three to 
four days. In a large majority of the cases that I have seen, the 
eruption has begun to appear in the course of the fourth day. 
This stage may, however, last only one or two days, or be pro- 
longed to five, six, or seven, and, according to Guersent and Blache, 
(Loc. cit. p. 659,) it lasted in one case, with all the characteristic 
symptoms, fifteen days. 

Second stage, or that of ervption. — The eruption generally ap- 
pears some time in the course of the fourth day, showing itself first 
on the chin or cheeks, or some other part of the face, and extend- 
ing gradually to the neck and trunk, and finally to the extremities. 
It is often completed in from twenty-four to forty-eight hours. It 
begins in the form of distinct spots, not unlike flea-bites, of a more 
or less bright rose or crimson colour, verging sometimes towards a 
deep red, of a roundish shape, with irregular edges, and of diffe- 
rent sizes, varying between half a line and three lines in diameter. 
When fully formed they constitute true papulae, which are felt to 
be slightly elevated and firm to the touch, with broad, flat sum- 
mits. When pressed upon, their colour disappears, but rapidly 
returns when the . pressure is removed. Distinct and scanty at 
first, the spots or stigmata soon become more numerous, and ar- 
range themselves into clusters of an irregular crescentic or semi- 



SYMPTOMS. 497 

lunar shape. The number of these clusters and the consequent 
general tint of the skin depend upon the amount and intensity of 
the eruption. In very mild cases, or when the eruption is imper- 
fect, the clusters of papulae are few in number, and separated by 
large portions of healthy skin. In severe cases, on the contrary, 
the patches are so numerous, and coalesce so closely, that the skin 
assumes a general deep red tint. Yet it ought to be remarked, 
that on close examination it can be observed that the papulae never 
run completely into each other, so as to form a continuous red 
surface, unless it be over very small spaces, and only in some 
parts of the surface, more particularly the face. 

The fever does not dimmish when the eruption makes its appear- 
ance, and sometimes augments. The skin retains its heat ; the 
irritation of the eyes continues and is sometimes very severe ; the 
nostrils are dry and incrusted, or there is coryza, and in some few 
cases epistaxis. The face is at the same time flushed, independently 
of the eruption, the red colour of the skin being observable in the in- 
tervals between the papulae, and it looks swelled and turgid, from tu- 
mefaction of the cheeks and particularly of the eyelids. The cough 
continues, and is loud, hoarse, and frequent in most cases, but in 
others short, scarcely hoarse, and but slightly marked. The voice 
is usually but not always a little hoarse. The respiration is 
slightly quickened in regular cases, but generally very little beyond 
the natural rate. The tongue is covered with a yellowish or 
whitish fur in its middle, while the edges and tip are clean and red. 
It remains moist and soft, unless some complication occurs. The 
tonsils, soft palate, and pharynx, present considerable redness, 
without tumefaction. The abdomen commonly remains natural, 
though in some few cases there is slight soreness over its whole 
extent or in the iliac fossae. Slight diarrhoea often occurs at this 
time. It seldom lasts more than from one to three days. In other 
cases ihe stools are natural, or there may be moderate constipation. 
The anorexia and thirst continue until the stage of decline occurs. 
About the time of the appearance of the rash, there is often con- 
siderable restlessness, anxiety, starting, and twitching in sleep, 
slight delirium, and in children old enough to describe their sensa- 

42* 



498 MEASLES. 

tions, complaints of headache. The strength of the patient is not 
decidedly affected in most of the cases. 

Stage of decline and desquamation. — The disease having 
reached its height in the course of the sixth day, the second of the 
eruption, remains nearly stationary for one or two days longer, 
and begins to subside about the seventh or eighth of the disease, or 
third or fourth of the eruption. The eruption fades first on the 
face and neck, and has often very much or wholly subsided on 
those parts while it is still vivid on the extremities. The papulae 
lose some of their colour, become less prominent, and diminish in 
size, and when pressed upon do not disappear entirely as they did 
at first, but leave a dull or yellowish stain behind. A little later, 
they assume a dirty yellow or copperish tint, which does not dis- 
appear under pressure, showing that a slight ecchymosis has taken 
place into the substance of the derm. These stains continue a 
variable length of time, and are finally removed by absorption. 
As the eruption disappears, a slight furfuraceous desquamation 
takes place in a considerable number of the cases, but not by any 
means in all. This begins usually about the face, and may either 
be limited to that part, or extend to other portions of the body. It 
is seldom general, however, and is often scarcely noticeable. It 
occurs between the eighth and eleventh days of the disease, or 
fourth and seventh of the rash. 

From the moment the eruption passes its highest point of inten- 
sity and begins to decline, the other symptoms do the same. The 
pulse rapidly loses in frequency, and regains its ordinary charac- 
ters. The heat of skin passes away, often with considerable per- 
spiration, but sometimes with gentle moisture only. The various 
catarrhal symptoms subside ; the cough is less frequent, loses its 
hoarseness, becomes softer, and gradually ceases entirely. The 
tongue cleans off; appetite returns ; thirst ceases ; the restless- 
ness and irritability disappear ; and the child returns to its ordi- 
nary condition of health. 

Irregularities of the disease. — Under this term I shall attempt 
to describe only the anomalous symptoms of the disease, which 
occur independently of complications. Those which are produced 



SYMPTOMS. 499 

by the latter cause will be fully treated of when I come to con- 
sider the subject of the complications. 

In some cases, the symptoms of the prodromic stage are so 
slight that they pass almost unobserved, and the child is scarcely 
thought to be sick until the rash makes its appearance. In others, 
owing to some peculiarity of the temperament, or to the state of 
the constitution at the time, they are much more severe than usual, 
or some one symptom may be in excess. In one case that came 
under my own observation, (June, 1847,) in a girl seven years 
old, the nausea and vomiting were very distressing, and accom- 
panied by the most intense frontal headache. She complained 
precisely as children generally do with tubercular meningitis, and 
was, moreover, extremely restless, and at night delirious. Never- 
theless, the eruption came out on the ^fourth day, was perfectly re- 
gular in its characters and course, the unpleasant symptoms ceased 
from that moment, and the patient recovered without any further 
bad symptoms. I have already spoken of two cases accompanied 
by general convulsions at the commencement of the first stage. 
The course of the disease in the subsequent stages, was regular in 
all respects. In two other cases, in girls, sisters, seven and nine 
years old respectively, of highly nervous temperament, the head- 
ache in the first stage was so intense as to require the application 
of leeches for its relief; yet the disease was regular in its other 
characters. 

The eruption presents various irregularities which ought to be 
noticed. It has already been stated that the amount of the rash 
varies according to the severity of the case, although in other re- 
spects regular. Sometimes the papulae are comparatively small in 
size and few in number, and consequently, the clusters in which 
they arc arranged have considerable spaces of healthy skin be- 
tween. When this is the case, the stigmata are usually rough, 
lighter in colour, and from this circumstance and the fact that the 
spaces between the clusters are large, the general tint of the skin 
is much less deep than in severer cases, in which the opposite of 
these characters prevails. In some of the mildest cases, the 
amount of eruption upon the extremities has been very small, or 
after forming, it has suddenly, in the space of a night, faded to 



500 MEASLES. 

such a degree as to seem almost a retrocession. But as this sud- 
den disappearance has not been accompanied or followed by bad 
symptoms, it is clear that its cause was merely the great mildness 
of the attack. In such instances the general symptoms have always 
been slight, and the whole duration of the sickness shorter by two 
or three days than in severe cases. 

I have already described the dull yellowish stains which remain 
after the papulae have faded. These stains sometimes assume, in 
malignant cases, a livid or purplish hue, from the occurrence of 
passive hemorrhage into the tissue of the derma. They may, how- 
ever, assume a dark and purpureous appearance, without any ma- 
lignant or dangerous symptoms whatever. This happened in a 
family in which I attended seven cases of the disease in 1845. In 
three of them (boys of 10, 5 and 1 year old, respectively), the 
eruption, which was copious and regular in all, became in one 
night, at the moment of decline, of a dark brown or light purple hue. 
The spots did not disappear at all under pressure, and were evi- 
dently formed by true ecchymoses. The general symptoms were 
all favourable. The only peculiarity to be observed was that the 
fever had disappeared very suddenly, and that the extremities were 
slightly cooler than natural. The convalescence was as usual, 
except that the ecchymotic spots disappeared very slowly and 
gradually. 

Several authors describe a form of measles without eruption. 
They state that during the epidemic prevalence of the disease, 
some children present all the catarrhal and febrile symptoms, 
without the eruption, and that they are protected against future 
attacks. The last assertion, at least, must be very difficult to 
prove. For my own part, I have never met with such cases, and 
should I ever seem to do so, would certainly not call them measles, 
lest by so doing the parents might be induced, on future occasions, 
to expose the child unnecessarily to the disease, when, should any 
evil consequences follow, they might justly question the wisdom of 
the physician. 

Willan and other authors have described another variety of the 

disease, to which is applied the term rubeola sine catarrho, or 

# measles without catarrhal symptoms. Such cases are said to 



SYMPTOMS. 501 

present no catarrhal symptoms whatever, and little or no febrile 
reaction. They are stated, moreover, to occur generally during 
the epidemic prevalence of measles. Most authors agree that this 
form does not protect the constitution against the true disease, and 
some regard it only as an eruption resembling measles, dependent 
upon gastric disorder. I at present recollect perfectly three cases 
of eruption in children, which had they been accompanied by 
cough and fever, I should certainly have called measles. They all 
occurred in infants. The rash was preceded for two or three days 
by feverishness, uneasiness, restlessness during sleep, and slight 
diarrhoea, after which the eruption suddenly made its appearance 
and covered the whole integument within twenty-four hours. There 
were no catarrhal symptoms whatever. At the same time the 
febrile symptoms disappeared and the children seemed quite well. 
The eruption never lasted over forty-eight hours, and disappeared 
without leaving a trace behind. These were, I believe, cases of 
roseola sestiva. T would ask whether those described by authors 
are not probably instances of the same kind 1 

Rubeola Maligna. — This form may occur either as an epidemic 
or sporadic affection. Generally, however, it prevails as an epi- 
demic, and depends upon some peculiarity which it is impossible 
to understand. The few sporadic cases which are met with, may 
be traced generally to some vicious state of the constitution of the 
individual, or to the unfavourable hygienic conditions in which he 
is placed. The symptoms assume ataxic or adynamic characters, 
which give to the case the features of the typhous or typhoid type 
of disease. They may make their appearance in the prodromic, 
or, as happens more frequently, not before the eruptive stage. 
When they begin in the first stage, the case is marked by 
great frequency and feebleness of the pulse ; by prostration ; by 
unusual dyspnoea and oppression ; and especially by greater 
violence of the nervous symptoms, as delirium or stupor. Some- 
times, even in this stage, petechia? make their appearance ; there 
are lividity and soreness of the fauces, discharges of dark blood 
from the nostrils, and sometimes profuse and exhausting diarrhoea 
or dysenteric discharges. When the time for the eruption to 
appear arrives, this comes out slowly and imperfectly, or irrcgu- 



502 MEASLES. 

larly, and generally assumes a livid, purplish, or blackish colour, 
owing to the passive exudation of blood into the papules, and 
hence the name sometimes given to it, of Rubeola Nigra, or black 
measles. This form of the disease assumes in fact, many of the 
features of purpura hemorrhagica. The patient may die of ex- 
haustion, of congestion of some important organ, as the brain or 
lungs, of the diarrhosa or dysentery which sometimes complicate 
the disease, or finally of the hemorrhages which occur in conse- 
quence of the dissolved and fluid state of the blood ; or he may, 
after a severe struggle with the violence of the disease, recover 
his health. 

Complications and sequelce. — Rilliet and Barlhez begin their 
chapter on the complications of the disease, with the following ex- 
cellent remarks. " Rubeola manifests itself by an inflammation 
or inflammatory fluxion of the skin and all the mucous membranes. 
The regular course of the disease depends upon the conservation 
of a due equilibrium between these two kinds of fluxions. That 
which is seated in the skin ought in general to predominate : if 
the equilibrium be destroyed by any cause whatever, whether 
accidental or inherent to the disease, if the predominance of the 
inflammation takes place in the mucous membranes, there will 
result a phlegmasia of some one of those tissues. 

" It is easy to foresee, by attention to these circumstances, that 
the inflammatory complications of measles will be most apt to 
fall upon the mucous membranes, and that broncho-pneumonia, 
pharyngo-laryngitis, and intestinal inflammations will be the most 
frequent of all." I am indebted to the work of Rilliet and Bar- 
thez for many of the facts in regard to the complications of 
measles. 

Bronchitis, Pneumonia, and Broncho- Pneumonia. — These 
constitute by far the most frequent and important of the compli- 
cations of measles. In 167 cases Rilliet and Barthez met with 
24 cases of bronchitis, 7 of pneumonia without bronchitis, and 58 
of lobular broncho-pneumonia. This statement shows how very 
large a proportion of the cases of measles occurring in the 
Children's Hospital at Paris, became complicated in the course of 
the attack. The proportion in private practice is much smaller, 



COMPLICATIONS. 503 

since in 137 cases, I have met with only 3 of bronchitis, 3 of 
lobar pneumonia, and 9 of broncho-pneumonia. They are, how- 
ever, in private practice, according to my experience, much the 
most important of all the complications likely to occur. Of 4 
deaths which occurred in the 137 cases that I have seen, 3 were 
caused by broncho-pneumonia. 

The time at which these different complications make their ap- 
pearance is important. This may happen during the prodromic 
stage, early in the eruptive stage, during the decline of the erup- 
tion, or after the eruption. The most common period for their 
occurrence is the prodromic stage. It is difficult or impossible to 
ascertain their causes in a great many cases. In some instances 
they evidently depend upon cold. Age has some influence upon 
their production, as broncho-pneumonia is most apt to occur in 
young children, whilst lobar pneumonia and simple bronchitis 
attack those who are older. 

The physical signs of these affections are the same as when 
they exist in the idiopathic form. The rational signs are increase 
of cough, which, instead of being merely laryngeal, becomes 
deeper and either pneumonic or catarrhal ; dyspnoea, which is 
sometimes excessive, the number of respirations mounting up 
to 40, 50, and, in severe cases, to 60 and 80 ; the pulse is more 
frequent than in regular measles, and in very bad cases becomes 
rapid and small ; the skin is hot and dry ; the face is pale and 
anxious in severe cases, in which the eruption does not appear ; 
the child is generally restless and irritable, with broken, irregular 
sleep, or in the most violent cases, is dull and soporose. In two 
of the fatal cases that came under my observation, convulsions 
occurred. It should be remarked, however, that in one, the child, 
a boy only nine months old, was labouring under an attack of 
hooping-cough, and that it was in one of the paroxysms of that 
malady, that the death took place. In the other case, that of a 
boy eighteen months old, the convulsions occurred first on the 
day of the eruption, and then ceased, to recur again the third day 
afterwards. The broncho-pneumonia dated from before the ap- 
pearance of the eruption, and was no doubt the cause of the con- 
vulsions and death. 



504 MEASLES. 

When a pulmonary complication begins in the prodromic stage, 
it almost always modifies the eruption in some manner, either re- 
tarding or rendering it irregular or imperfect. When it dates 
from the second stage, it may cause a partial or complete retroces- 
sion of the eruption. I have known the eruption to be retarded 
one and two days, so as not to come out until the fifth or sixth. 
When the rash does appear, whether at the usual period or 
later, it is evidently with difficulty. It is pale and scanty, or 
abundant on one part of the body, and scanty on another, or 
appears and disappears alternately. At length it either comes out 
fully, and the threatening symptoms pass away, or the eruption 
lasts the usual, or nearly the usual length of time, in its pale and 
imperfect condition, and the child recovers slowly and gradually 
from the complication, which has become the most important part 
of the sickness ; or, in fatal cases, the symptoms grow worse and 
worse, and the child dies after a few days, or a longer time, accord- 
ing as the inflammation assumes the acute or chronic type. 

Whenever it is observed in a case of measles, that there is more 
drowsiness or irritability than usual, that the pulse is more frequent 
or stronger than it ought to be, it becomes important to ascertain 
carefully the state of the respiration. If this be accelerated, the thorax 
ought to be examined with strict attention by auscultation and per- 
cussion, to discover whether there be not some pulmonic inflamma- 
tion at work, likely to convert the disorder from a mild one, as it 
almost always is when uncomplicated, into one dangerous to life, 
which it will assuredly become, should any pulmonic complication 
be allowed to steal unawares upon the patient. 

The prognosis of the pulmonic complications of measles would 
appear to be very unfavourable in hospitals for children, since 
Riiliet and Barthez state that scarcely one patient in four or five 
recovered. Of the 15 cases that I have seen, I have already 
stated that 3 died of broncho-pneumonia, and if we recollect that 
one of these was complicated also with pertussis and morbid den- 
tition, it will be seen that the prognosis is, as might be expected, 
vastly more favourable in private than in hospital practice. 

Laryngitis is a common complication of the disease. The au- 
thors just quoted, met with it in 35 of their 167 cases. It occurred 



COMPLICATIONS. 505 

in 7 of the 1 37 cases that came under my observation. It is often 
accompanied by pharyngitis. 

Autopsies show that the laryngitis may be slight, severe, or ac- 
companied with pseudo-membranous exudations. The inflamma- 
tion may be simple, therefore, consisting merely of different de- 
grees of redness, or of redness with thickening and softening of the 
mucous membrane ; it may be more intense and accompanied by 
ulcerations or erosions ; or, lastly, it may be associated with an 
exudation of false membranes. 

The symptoms of this complication will depend upon the form 
the inflammation assumes. It is unnecessary to describe them 
here, as they are the same as those of the idiopathic affection, 
which has already been fully treated of. 

The occurrence of laryngitis exerts but little influence on the 
rash, particularly as it almost always appears during the decline 
of the latter. It is seldom fatal, unless it assume the pseudo- 
membranous form. The seven cases that came under my obser- 
vation were attacks of the simple disease, and all recovered. 

Inflammation of the intestines. — According to Rilliet and Bar- 
thez, lesions of the intestinal mucous membrane are the most fre- 
quent complications after pulmonary affections. About a third of the 
cases presented at the autopsy erythematous inflammation of the 
mucous membrane ; a fifth offered follicular entero-colitis ; a seventh 
ulcerative inflammation, and a fourth softening. Some presented 
several of the lesions united, and in a few no lesion was found, 
though the symptoms of entero-colitis had existed during life. I 
give these data from the above authors, not because they apply to 
private practice generally, but merely in order to show what are 
the tendencies of the disease, when disposed from unfavourable 
hygienic conditions to take on complications. I have met with 
only six instances of intestinal inflammation in the 137 cases that 
have come under my own observation. Four of these occurred in 
the same family, in children of seven, five, three, and one year old 
respectively. They were cases of entero-colitis, accompanied in 
two, with dysenteric symptoms, and all made their appearance 
towards the close of the disease. The two remaining cases were 

43 



506 MEASLES. 

attacks of dysentery, one of which was very severe, the stools 
amounting to twenty in the day, while the other was much less so. 

The intestinal complications may appear during the prodromic 
stage, or on the day of eruption, and if not at one of those pe- 
riods, are most apt to occur during the decline of the rash. The 
slight cases, constituting the common diarrhoea of the disease, ge- 
nerally begin early, while the grave cases usually date from a later 
period of the disease. The causes of these complications seem to 
be various exciting agents acting upon a mucous membrane predis- 
posed, by the nature of the disease, to inflammatory action. These 
agents are said to be generally improper food, giving rise to indi- 
gestions ; and the too early use of purgative remedies, and laxa- 
tives. In the cases' observed by myself, it was impossible to detect 
the causes. 

The symptoms are more or less abundant diarrhoea, and in 
some, but not all the cases, sensibility with tumidity and tension 
of the abdomen. This complication does not exert much influence 
upon the measles, which usually pursue their regular course. 
Sometimes, however, it occasions an aggravation of the febrile 
symptoms, and when of a grave character, may no doubt interfere 
with the regular progress of the eruptive disease. 

According to Hilliet and Barthez, this complication was very 
seldom the only, or even chief cause of a fatal termination. 
Scarcely five or six of all that they observed, could be con- 
sidered as of that kind. It increases very much, however, the 
danger of the pulmonic attacks, for the latter are much less 
serious, so long as they exist alone, while as soon as intestinal in- 
flammation is added to them, they become almost necessarily fatal. 
The six cases that I met with recovered under simple treatment. 

In a considerable number of cases, a slight diarrhoea, to which 
I have already referred as a common event in measles, occurred, 
but only in the six above mentioned did it amount to a serious 
complication. 

There are several other disorders which sometimes complicate 
or follow measles, but as I have already given as much space to 
this subject as the limits of the work will allow, I shall be satisfied 
with a simple enumeration of them. They are otitis, ophthalmia, 



COMPLICATIONS ANATOMICAL LESIONS. 507 

hemorrhages, stomatitis, tubercles, other eruptions, anasarca, and 
different cerebral symptoms. 

I may mention here that of the whole 137 cases that I have 
seen, 105 were simple, and 32 complicated. The complications 
were as follows : bronchitis, pneumonia, and broncho-pneumonia, 
15 ; laryngitis, slight or severe, 7 ; entero-colitis, 6 ; pertussis, 7 ; 
scarlatina, 2 ; convulsions, 4 ; otitis, 3 ; erysipelas, 1 ; and me- 
ningitis, 1. In this enumeration, some of the cases are referred to 
twice, and one, that in which pertussis, broncho-pneumonia, and 
convulsions occurred, three times. 

I will merely add, that measles are supposed by many observers 
to have a special tendency to develope tubercular disease in the 
system, and that it is necessary, therefore, to treat a child, show- 
ing any predisposition to that diathesis, or one born of tubercular 
parents, with particular caution, both at the time of the disease, 
and during the convalescence. It is not uncommon for measles 
to be conjoined with other eruptive diseases. I have known it to 
co-exist with scarlatina in two instances, and Dr. G. B. Wood has 
met with a fatal case of the same nature. It may be associated, 
likewise, with variola, or with erysipelas, of which I have met with 
one instance. 

Anatomical lesions. — It is difficult to ascertain what are the 
characteristic lesions of measles, because of the fact that most of 
the fatal cases prove so in consequence of some complication. 
Some few fatal cases, however, of the regular form, and some in 
which the complication was so slight as not to be likely to change 
the autopsical appearances much, have led to the following con- 
clusions. 

The lesions peculiar to measles are general congestion of diffe- 
rent organs, which are coloured red from the imbibition of blood 
and sometimes softened. The congestion affects the mucous mem- 
branes particularly, and imparts to them a reddish or slightly 
blackish colour. In some of the cases there is morbid develop- 
ment of the intestinal follicles. The most important lesion, how- 
ever, is that of the blood, which presents the appearances com- 
mon to the class pyrexiae. These are normal proportion or dimi- 
nution of the fibrinous, with increase of the globular element of 



508 MEASLES. 

the blood. Dr. Copland [Diet. Pract. Med. vol. ii, p. 819), gives 
the appearances in a few fatal cases of malignant measles. They 
were softening of the tissues and the facility with which they were 
torn ; the presence, in some of the cases, of a turbid or sanguineous 
serous fluid in the serous cavities ; general congestion of the lungs ; 
dark appearance, or livid, or purple ecchymoses of the bronchial 
mucous surface, fauces, stomach, and csecum ; engorgement with 
dark and semi-fluid blood of the veins and sinuses of the brain, 
and of the auricles and large veins ; and finally a livid and mot- 
tled appearance of some parts of the body, with petechias of a 
dark colour. 

Diagnosis. — It is impossible to diagnosticate measles in the first 
stage with any considerable certainty. The existence of the dis- 
ease may be suspected in that period from the appearance of the 
eyes ; the coryza and sneezing ; the frequent, hoarse, scraping 
cough ; and the fever, headache, and thirst. If, in connexion with 
these symptoms, it happens that an epidemic of measles be pre- 
vailing at the time, or that the child has been exposed to the con- 
tagion of the disease, the inference becomes still more plausible. 
Nevertheless, any opinion upon this point ought to be given with 
much reservation. 

After the eruption has fully come out it is not likely to be mis- 
taken for any other disease, unless it be roseola, the rash of which 
sometimes resembles that of measles very closely. It may be distin- 
guished, however, by attention to the concomitant symptoms ; by 
the slight degree of fever, the more rapid evolution of the rash, and 
the absence of the peculiar catarrhal symptoms in roseola. In the 
very early stage of the eruption of measles, it may be confounded 
with variola. A careful attention, however, to the size and shape 
of the papulce, which are much larger, flatter, and less elevated in 
measles, and the presence of the catarrhal symptoms will usually 
suffice to show the difference even in the earliest stage. A. little 
later, the appearance of vesicles on some of the papula? about the 
face in variola, will show the difference still more strongly. The 
distinction between measles and scarlatina has already been drawn 
in the description of the latter disease. It rests chiefly on the 
much shorter duration of the prodromic stage, on the greater vio- 



DIAGNOSIS PROGNOSIS. 509 

lence of the anginose symptoms, or the absence of the peculiar 
catarrhal symptoms, on the more rapid evolution of the eruption 
in the latter disease ; and lastly, on the differences in the two erup- 
tions, observable especially at their first appearance. 

When measles are conjoined with some other eruption, the 
diagnosis is to be made out by careful study of the prodromes, 
and of the eruption on different parts of the body, for we can ge- 
nerally find well-marked patches of the rash peculiar to each 
on some portions of the surface. In one of the cases of measles 
and scarlatina that I saw, the latter disease was first developed. The 
eruption made its appearance in the usual form ; on the second 
day of the eruption, the child was seized with hard, hoarse, laryn- 
geal cough, and with redness of the eyes and lachrymation. These 
symptoms continued three days, at the end of which time the 
scarlatinous rash had disappeared from the face, but remained 
visible upon the trunk and extremities. Characteristic measly 
papulae now made their appearance on the face, and pursued their 
regular course, while on the trunk and extremities, the measly 
eruption was never well defined, being mixed and disguised, as it 
were, by that of the scarlatina. In the other case, the measles 
appeared first, and went on regularly until the eruption was de- 
clining, and the general symptoms moderating, when suddenly the 
fever, heat of skin, restlessness, and irritability returned, and the 
child was very soon covered with the punctuated scarlet rash of 
scarlatina. 

Prognosis. — The prognosis of simple, uncomplicated measles is 
very favourable; the cases almost always recover without diffi- 
culty. This is shown to be true by the following facts. Rilliet 
and Barthez report 36 cases of simple measles, of which all but 

] one recovered. Of 105 cases that I have seen, all terminated 
favourably. When, on the contrary, complications occur, the 
disease always becomes more or less dangerous, the degree of 
danger depending on the nature of the intercurrent affection, and 
the hygienic conditions in which the patient is placed. Thus, of 

> 131 cases observed by the above authors, in which some form of 
complication occurred, 89 or about two-thirds proved fatal, while of 
the 32 complicated cases that I have seen, 4 only were fatal. It 

13* 



510 « MEASLES. 

must be recollected that the cases of the French observers all oc- 
curred under the unfavourable hygienic conditions of a large 
hospital, in children of bad constitution from congenital or ac- 
quired causes, whilst mine were observed in private practice, 
where the hygienic conditions are favourable in the same degree 
as they are unfavourable in hospitals. 

The four fatal cases that came under my observation, proved 
so from the circumstances I am about to mention. The first, 
occurred in a child, nine months old, who was labouring under 
pertussis when attacked with measles. Broncho-pneumonia super- 
vened upon the measles, and proved fatal by convulsions, which 
came on during a paroxysm of hooping-cough, two weeks after the 
disappearance of the rubeola. The second case was that of a boy 
eighteen months old, who was prescribed for by an apothecary from 
behind his counter, until I saw him. The eruption made its appear- 
ance imperfectly, I was told, with a convulsion. After this, he 
was very restless, and had rapid and difficult respiration and much 
cough. On the morning of the fourth day of the eruption, this had 
almost entirely disappeared, and the child was again attacked with 
convulsions. I saw him shortly after this for the first time, and 
found him comatose, with convulsive movements of the limbs, ex- 
treme dyspnoea, and all the symptoms of extensive broncho-pneu- 
monia of both lungs. He died 36 hours after this, as was to be ex- 
pected. The third was also a case of pneumonia in a child between 
one and two years of age, in which the inflammation came on as 
the eruption was fading, and proved fatal in spite of all that could be 
done, on the eleventh day. The fourth occurred in a boy between 
four and five years old, who appeared to recover perfectly from the 
measles, but was attacked in ten days with meningitis, and died. 

To conclude, we may state that the prognosis is always highly 
favourable under the following circumstances : when the disease 
is primary ; when the prodromic stage is of the proper duration ; 
when the eruption begins upon the face and extends gradually to 
the rest of the body ; when the febrile movement is moderate ; 
when the eruption, after increasing for one, two, or three days, 
gradually decreases ; when the cough and other concomitant symp- 
toms diminish with the fever ; when the cutaneous surface, after 



PROGNOSIS TREATMENT. 511 

the fading of the rash, assumes a natural colour, and is neither 
flushed nor pale ; when the appetite returns, the disposition to be 
amused and take notice continues, and lastly when the sleep is 
natural. 

On the contrary, the prognosis becomes unfavourable under the 
following circumstances : when the prodromic stage lasts longer 
than usual, and when it is accompanied by violent symptoms of 
any kind, as extreme jactitation, irritability, dyspnoea, much stupor, 
coma, or convulsions ; when the eruption is irregular in its appear- 
ance or course ; when the fever does not disappear with the erup- 
tion, whether it remains violent or assume the form of hectic; when, 
after the eruption, the face continues deeply flushed or becomes 
very pale ; when the cough, dyspnoea, or diarrhoea persist; and 
lastly, when the child remains weak, languid, dispirited, or irri- 
table. 

It may be stated in conclusion, that the prognosis of measles is 
always favourable in proportion to the health of the child at the 
time of the invasion, and the regularity with which the disease 
passes through its different phases ; while it becomes unfavourable, 
though far less so in private practice amongst people in easy cir- 
cumstances, than in hospitals or amongst the poor and wretched, 
whenever it attacks a child already labouring under some disease, 
and when it becomes complicated with any other malady, either 
local or general. 

Treatment of the regular, simple form. — This form requires in 
the great majority of the cases little other treatment than strict 
attention to the hygienic condition of the patient, the use of simple 
diaphoretics, of mild cathartics occasionally, and the palliation of 
any of the symptoms which may chance to become somewhat 
more troublesome than usual. 

Hygienic treatment. — The child ought to be confined as much 
as possible to bed in a large, well-ventilated chamber. Every pre- 
caution should be observed to prevent chilliness, while at the some 
time it is nearly, if not quite as important, to avoid over-heating 
the patient, either by excessive clothing or by keeping the tempe- 
rature of the room too high. In winter, it is well to direct the 
temperature to be maintained at between 68° and 70° F., night and 



512 MEASLES. 

day. If this be done, the child is not apt to take cold, even though 
it be uncovered at times, and yet the warmth is not oppressive. I 
have often remarked that this temperature is just what it ought to 
be when the room is well ventilated, either by means of an open 
fire-place, or by communication with adjoining rooms ; but when, on 
the contrary, the room is heated by a furnace flue, and not ventilated 
at all or very imperfectly, the same temperature as indicated by 
the thermometer becomes extremely close and oppressive. Under 
such circumstances, a door into an adjoining room, or if this cannot 
be, one into the entry, ought to be kept more or less open, with a 
screen of some kind between it and the child, in order to secure a 
good ventilation, which is assuredly of the very highest importance, 
and yet to prevent by the screen a current of cool air from chilling 
the patient. The diet during the febrile period ought to be very 
light. It may consist of milk and water, of arrow-root, sago, 
or tapioca, prepared with milk or water ; or of crackers soaked 
in water with salt, or some similar food. When the eruption and 
fever have in great measure disappeared, some light broth, either 
vegetable or animal, with dry toast or bread ; plain boiled rice ; a 
roasted potato ; or ice cream, may be added ; and after all the 
symptoms have ceased, the usual diet can be gradually resumed. 
The drinks may consist of simple water, of lemonade, orangeade, 
gum water, or flax-seed tea, with the addition of a little sweet nitre ; 
or of weak infusions of balm, sweet-marjoram, or saffron. They 
may be given in any reasonable quantity, at the temperature of the 
room. Some persons have a great dread of cold water in the 
disease. I have never seen small quantities (half a wineglassful to 
a wineglassful at a time,) of the coldest water do any harm, and 
believe it to be useful when the fever is violent, and the heat very 
great. I once, however, saw a boy nine years old, attacked with 
violent colic and partial retrocession of the eruption, after swal- 
lowing suddenly a tumbler full of iced water. The unpleasant 
symptoms passed off in a kw hours, and he had no difficulty after- 
wards. 

The child should not be permitted to leave the room until a few 
days after the entire disappearance of the disease. It ought to be 
kept in the house until it has regained in some measure its strength 



TREATMENT. 513 

and healthful looks, as it will scarcely be able to resist exposure 
before. 

Therapeutical treatment. — The therapeutical management of the 
regular form ought to be very simple. When the bowels have not 
been open naturally for one or two days, it is proper to direct an 
enema to be used, or, if the fever and restlessness are considerable, 
some mild laxative, as a teaspoonful or dessert-spoonful of castor- 
oil, a dessert or tablespoonful of syrup of rhubarb, half a teaspoon- 
ful of Henry's magnesia to older children, or less to younger, 
or some similar remedy, always selecting those which are mild, 
and giving them in small doses, lest they irritate the gastrointes- 
tinal mucous membrane. It is better to give a small dose and re- 
peat it in four or six hours, or assist it by an enema, than to give 
such a quantity as might produce over-purging, and thus perhaps 
disturb the regular progress of the eruption. The laxative may be 
repeated from time to time throughout the disease, if the bowels are 
not opened naturally. After the laxative we may either do nothing, 
when the case is mild and progresses favourably, or give one of the 
infusions above mentioned, or a little sweet spirits of nitre. If the 
reaction, however, be considerable, with much headache, restless- 
ness, and dry, hot skin, I would give small doses of antimonial 
wine and sweet spirits of nitre, (half a 'drop to three or four drops of 
the former, with five or ten of the latter,) every two hours, and direct 
a warm mustard foot-bath to be given twice a day. If the fever be 
violent, with frequent, strong, full pulse, intense heat of skin, severe 
headache, and much restlessness, even without any present sign of 
local disease, it would undoubtedly be correct to resort to moderate 
depletion, in order to prevent the formation of any local affection, 
or to relieve any which may be in process of formation, though not 
as yet indicated by local symptoms. Of the 105 regular cases that I 
have seen, depletion was employed only in 2 ; in one a venesection 
of four ounces in a boy seven years old, in consequence of the 
great violence of the reaction, and not from any discoverable local 
affection ; and in the other, the application of leeches to the tem- 
ples, for intense headache, in a girl nine years old. Under the 
same circumstances a warm bath, given with care, and continued 
for fifteen or twenty minutes, will be found of great service ; or, 



514 MEASLES. 

a simple foot-bath may be used and repeated three or four times in 
the course of a day. 

If any of the local symptoms become particularly troublesome, 
they should be palliated by simple treatment. When the cough is 
very frequent and hard, it is most effectually moderated by 
some anodyne, which may be given in most cases without any 
detriment. The only contra-indication to its use is the presence 
of severe headache or some other cerebral symptom. A mild 
counter-irritant application to the outside of the throat is also use- 
ful ; T have generally used sweet oil and spirits of hartshorn. 
When the conjunctival inflammation is acute and painful, it may 
be relieved by lotions with simple warm water, milk and water, or 
sassafras-pith mucilage, alone or mixed with rose water. If the 
headache be very violent it can generally be relieved by the use of 
a laxative, by the occasional use of a mustard pediluvium, or a 
sinapism to the nucha. When very severe and attended with much 
fever, it is safest to direct an application of leeches to the temples. 

The malignant form, of the disease must be treated chiefly 
with stimulants and tonics. The most useful are wine and brandy, 
quinine, ammonia, capsicum, etc. Camphor and opium would be 
proper, were the case attended with severe nervous symptoms. 
The diet ought to be nutritious and digestible, and may consist of 
milk and bread, light broths, and beef tea or essence of beef. 

When local inflammations occur, they may be treated by a 
small venesection if it can be borne, by a few cups or leeches, or 
by means of counter-irritants, of which the most suitable are 
mustard, spirits of turpentine, or ammonia. Blisters ought to be 
avoided, as they are very apt to occasion dangerous and even fatal 
sloughing. 

Treatment of the complications. — Broncho-pneumonia, pneu- 
monia, and bronchitis. — The treatment of these complications 
must depend upon the stage at which they are developed, and 
upon the age and constitution of the subject. When they occur 
during the first stage, one of the most important points in the 
treatment is to endeavour to favour the appearance of the eruption, 
and when in the second stage, and the eruption has retroceded 
wholly or in part, the same indication applies with equal force. 



TREATMENT. 515 

When they appear during the third stage, they are to be treated 
without any regard to the eruption, but always with reference to 
the fact that the patient has just passed through an acute febrile 
disease, which must have weakened in some degree the vital 
powers. 

It may be stated in general terms, that the treatment proper for 
these local inflammations when they occur as primary affections, is 
proper also, with some reservations, under the circumstances we 
are now considering. Thus, bloodletting ought to be, resorted to 
in many of the cases, but always with caution, since it is perfectly 
true that it cannot be used safely with the same freedom in secon- 
dary as in primary phlegmasia. In children under two years 
of age I have generally employed leeches, while in those over that 
age, I have resorted to venesection, and in one case to venesection 
and leeching both. In all such cases I have used depletion with 
greater moderation than in primary cases, rarely applying more than 
a dozen American leeches at once, or taking more than four ounces 
of blood from the arm. Purgatives may be used in conjunction 
with the depletion, always, however bearing in mind in the choice 
of them, and the doses, the disposition to gastro-intestinal irritation 
which is inherent to the malady. The antimonial preparations are 
also useful, given however with greater care than usual. I gene- 
rally employ antimonial wine with sweet nitre, or a solution of 
tartar emetic in simple water. Of the latter the thirtieth or for- 
tieth of a grain for very young children, and the twentieth or 
thirtieth for those who are older, given every half hour or hour, 
is enough. If the quantity first given produces either sickness or 
diarrhoea, it should be instantly suspended or very much reduced 
in strength. For children within the year, the syrup of ipecacu- 
anha, in doses of two to five drops every hour or two, is, perhaps 
•preferable to antimonials. When in these cases the skin is at all 
coolish, or bathed with too considerable a perspiration, I have 
found the liquor ammonia? acetatis a very useful remedy. 

It is universally acknowledged to be exceedingly important to 
assist nature in throwing out the rash, whenever these complica- 
tions either prevent its formation, or cause its retrocession. The 
true mode of doing this is to cure or alleviate the internal inflam- 



516 MEASLES. 

mation, which is the cause of the difficulty. With this end the 
above plan of treatment ought to be instituted at once. At the 
same time, we may greatly assist the appearance of the eruption 
by a persevering employment of counter-irritants. The best of 
these is, I believe, mustard, and in some cases a warm bath. The 
mustard may be used in the form of plasters, poultices, or baths. 
My own plan in moderately severe cases, is to direct a mustard 
poultice to the interscapular space, and a mustard pediluvium, to be 
employed two or three times a day, while in severe and urgent 
attacks I direct the cataplasm and bath to be renewed every two or 
three hours, taking care, however, to apply the former alternately 
to the front and back of the chest, in order to avoid all possibility 
of too violent an action upon the skin ; the feet and limbs also 
ought to be carefully watched, to avoid the same danger. I have 
had occasion to observe the great efficacy of this unremitting em- 
ployment of revulsives, in several severe cases of broncho-pneu- 
monia in young children. In some I have depended solely upon 
this treatment, and the use of small doses of ipecacuanha, and 
spiritus Mindereri. In one particularly, which occurred in a child 
eight months old, the attack came on in the first stage. On the 
fourth, fifth, and sixth days, the dyspnoea was excessive, the 
respiration running up to 70 and 80 ; the pulse was frequent and 
small ; the skin pale and rather cool ; and the irritability and rest- 
lessness very great. For a period of twenty-four hours, I used 
the poultices and foot-baths every two hours regularly, and gave 
internally the spiritus Mindereri at the same intervals. Nothing 
else was done. On the sixth day, when one of the poultices was 
removed from the interscapular space, the integument beneath was 
observed to be covered with the measly stigmata, whilst there were 
none as yet on any other part of the surface. From this time the 
eruption came out freely, and the child recovered rapidly. 

The warm bath may be used under the same circumstances. It 
should be given with great care, the child being wrapped in a 
warm blanket the moment it is removed from the water, to pre- 
vent the least sensation of chilliness. It may either lie for a short 
time in the blanket, or be wiped dry beneath it, and then dressed. 

The cases of bronchitis have seemed to me to require less de- 



TREATMENT. 517 

pletion than those of pneumonia or broncho-pneumonia, and the 
latter less than those of pure pneumonia. In some of the cases 
of bronchitis, there has been profuse secretion attended with ex- 
tensive sub-crepitant and mucous rales. In such instances I have 
found the internal use of the syrup or infusion of polygala seneka, 
with an occasional revulsive, very effectual. 

The diarrhoea which occurs so frequently, seldom requires any 
treatment. Indeed, unless it indicates evident entero-colitis, or is 
accompanied by frequent mucous or bloody stools, pain and tenes- 
mus, it is better not to interfere with it, beyond paying strict attention 
to the diet. When attended, however, with the symptoms just men- 
tioned, it must be treated by astringents, by opium and ipecacuanha, 
and by the application of poultices to the abdomen. The six cases 
that occurred to myself recovered under the use of laudanum 
enemata, given twice or three times a day, the strictest diet, and 
very small doses of Dover's powder. 

Laryngitis, as it occurs in most of the cases, needs but little 
treatment beyond careful avoidance of cold, the use of some 
mild nauseant, and revulsives to the neck. It is very seldom of a 
dangerous character. When, however, it assumes the character 
of pseudo-membranous croup, it must be treated with all activity, 
in the manner described in our article upon that disease. In only 
two of the seven cases that I have seen, did it appear at all 
threatening. One of these occurred in a boy ten years old, and 
came on in the first stage. The voice was very hoarse and diffi- 
cult, the cough frequent, hoarse, and croupal, and preceded and 
followed by loud stridulous respiration. Fearing the formation of 
false membrane, though none was visible in the fauces, I ordered 
a venesection of four ounces, and doses of hive syrup every two 
hours, and finding at the end of six hours that there was no im- 
provement, I had between three and four more ounces of blood 
taken from the throat by leeches. This was followed by slow but 
steady amendment of the symptoms ; the eruption came out well, 
and no further difficulty occurred. The second serious case 
occurred in a boy between one and two years old, also in the first 
stage. The symptoms were like those of the first case. They 
were treated by an application of leeches to the throat, and by an 

44 



518 MEASLES. 

emetic of alum, which relieved them very much, and they dis- 
appeared gradually. The eruption pursued its regular course. 

The cerebral symptoms which sometimes occur, must be treated 
differently in different periods of the disease. Tn the early stage, 
when they last but a short time and do not recur, they require 
nothing more than a warm bath, and the use of revulsives. If 
they continue or recur, or are followed by stupor or other cerebral 
symptoms, more energetic treatment becomes necessary. If the 
child is strong and hearty, it would be proper to resort to de- 
pletion, either by venesection, or by cups or leeches to the back of 
the neck, or temples, and to purgatives, revulsives, and cold 
applications to the head. When it does not seem proper to 
bleed, and when the heat is intense, it has been proposed to use 
cold lotions in the manner recommended in scarlatina. The evi- 
dence upon this point is not very conclusive, and as I have never 
used them, nor seen them used, nor indeed seen any necessity for 
a resort to them, I can offer no opinion in regard to their use. 

I have met with two cases of convulsions in the first stage. 
One occurred in a boy five years old ; the convulsions were slight, 
lasted not more than ten or fifteen minutes, and were followed by 
no bad symptoms. The intelligence of the child returned very 
soon afterwards. The only remedy used was a warm bath. The 
other case has already been described. 

When convulsions occur in the second or third stages, it is very 
important to ascertain whether they are not the result of some 
local disease. The only two cases that came under my notice 
accompanied very violent attacks of broncho-pneumonia. Here 
the treatment must be directed against the local disease, if that 
can be detected. When, on the contrary, the convulsions seem to 
depend on nervous irritation, they may be treated with baths, re- 
vulsives, purgatives, and the careful administration of opium, as 
recommended by Sydenham, Copland, Rilliet and Barthez, and 
other authors ; or of camphor, assafcetida, musk, or hyoscyamus. 
If accompanied by intense heat and great dryness of the skin, 
without local complications, the cold or tepid lotions might also be 
tried. 



SMALL-POX. 519 



ARTICLE III. 



VARIOLA. OR SMALL-POX. 



Definition ; frequency ; farms. — Variola is an epidemic and 
contagious disease, characterized by an initial fever, lasting from 
three to four days, and followed by an eruption at first papular, 
then vesicular, and afterwards pustular ; the eruption attains ma- 
turity in from six to nine days, after which the pustules are con- 
verted by desiccation into scabs, which fall off between the fifteenth 
and twenty-fifth days. 

The frequency of the disease varies greatly in different years, 
because of its epidemic nature. It is far less common in child- 
hood amongst the middle and upper classes of the community, 
than either measles or scarlatina, in consequence, no doubt, of the 
attention paid to vaccination. I have seen but two cases of the 
disease under fifteen years of age, in upwards of seven years, 
whilst 1 have met with 82 of scarlatina, and upwards of 137 of 
measles. It prevails to a greater extent amongst the poor and 
destitute classes, who neglect the attention to vaccination neces- 
sary to preserve children from the disease. Dr. Condie (Dis. of 
Children, note, p. 86) states that 587 deaths under fifteen years 
of age, occurred from this disease in the ten years preceding 
1845, while in the same period, there were 574 from measles, 
and 2154 from scarlatina. 

I shall describe two forms, the regular, including the distinct or 
discrete, and confluent varieties of most writers, and the modified 
form or varioloid. I shall afterwards treat of the irregularities 
and complications of the malady. 

Causes. — The principal cause of variola is universally acknow- 
ledged to be contagion. It is generally admitted also that it is 
propagated at certain periods by epidemic influence. 

It is not clearly ascertained at what period of its course the 
disease first becomes contagious. Some assert that it is not until 
after suppuration is established. This is, however, to say the least, 
doubtful, and it is best, therefore, to take any precaution that may 



520 SMALL- POX. 

be necessary to prevent the extension of the disease from the mo- 
ment that its real nature becomes apparent. There can be no 
doubt that the body may still impart the disease after death, and 
that clothes worn by the patient retain the contagious principle, 
unless freely exposed to the air, for days, months, and, it is said, 
even for years. 

One attack protects the constitution, in the great majority of 
cases, against subsequent contagion. When persons who have 
once had the disease contract it again, it almost always assumes a 
milder and much less dangerous form. 

The period of incubation, or time elapsing between the re- 
ception of the poison and beginning of the malady, varies gene- 
rally between nine and twelve days. It may, however, be more 
or less than the periods just mentioned. 

Symptoms ; course ; duration. — Regular form of the disease. — 
I shall describe three stages of the disease : 1. That of the initial 
or eruptive fever; 2. That of progress and maturation of the erup- 
tion ; and, 3. That of decline or desiccation. In addition to these 
some writers make another stage, that of incubation, which in- 
cludes the period between the introduction of the poison into the 
system, and the appearance of the first symptoms. This stage is 
seldom marked by symptoms sufficiently characteristic to enable 
us to detect the approaching disease, and in many instances is 
probably entirely unnoticed by the patient. 

The first stage, or that of initiatory fever, commences generally 
in children with pains in the bones and loins, and sometimes with 
rigors or chilliness, accompanied with headache, and soon followed 
by fever. Nausea and vomiting often exist from the first, or 
come on soon after the appearance of fever and headache. At the 
same time there is loss of appetite, thirst, and more or less obsti- 
nate constipation. The tongue is red at the point and edges ; one 
of the characteristic symptoms of this stage is pain in the loins, 
which generally dates from the first or second day, and though 
varying much in degree, is usually severe. The patients often 
complain also of abdominal pains, which seem to be colicky, and 
are referred either to the epigastric or umbilical region. 

Fever and headache are the most constant of all the prodromic 



SYMPTOMS. 521 

symptoms. The chilliness and rigors which frequently exist in 
adults, are not easily ascertained in the cases of children, and are 
therefore much less important. The fever varies greatly as to 
degree ; the heat of skin is generally considerable ; and may be 
accompanied either with dryness or moisture. The pulse is com- 
monly full and frequent. The headache is usually frontal and 
often very severe. In some cases there are strongly marked cere- 
bral symptoms, consisting of excessive restlessness and irritability, 
insomnia or somnolence, delirium and even convulsions. 

The various symptoms just enumerated continue up to the mo- 
ment when the eruption begins to make its appearance, which 
happens generally in the course of the third day, though it may 
occur as early as the second, or as late as the fifth, sixth, or even 
seventh. In severe and confluent attacks, the eruption, as a general 
rule, begins earlier than in mild and distinct cases. 

Second stage, or that of eruption. — Some time in the course 
of the third day after the invasion of the attack, the eruption 
usually begins to make its appearance in the form of small, 
isolated, and rounded red specks, which soon become projecting 
and solid, or in other words are converted into papules. The 
papules are from a third to two-thirds of a line in diameter, of a 
more or less vivid red colour, and disappear under pressure, to re- 
turn immediately when the pressure is removed. The eruption 
shows itself first on the face, and generally about the chin and 
mouth, and then extends to the rest of the face, to the neck, trunk, 
limbs, feet, and hands. It sometimes happens, particularly in very 
young children, that the eruption appears first about the genital 
organs, whilst in other cases it is first observed on the lower part 
of the loins, or upon the thighs. The papules increase gradually 
in size and prominence for one, two, or three days, and, as a ge- 
neral rule, some time in the course of the second day of the erup- 
tion, undergo a change into vesicles. This change takes place by 
the formation on the top of each papule, of a little transparent 
elevation of the cuticle, beneath which is deposited a drop of 
serosity. The conversion of the papules into vesicles occurs first 
on the face, and then on the neck, trunk, and extremities. The 
vesicles are at first smaller than the papules, and acuminated in 

44* 



522 SMALL-POX. 

shape, but as they grow larger, become gradually flattened and 
depressed in the centre ; after a time they cover the whole papule, 
and before long exceed it in size. As these changes take place, 
the fluid they contain loses its transparency, becomes opaline, and 
by degrees the vesicles are transformed into pustules, which con- 
stitutes the third stage of the eruption or that of suppuration. 

The pocks are more or less numerous, according to the ex- 
tent and severity of the eruption. When scattered over the sur- 
face so as not to touch at their edges, the disease is said to be 
distinct ; when, on the contrary, so numerous as to come into 
contact, and run together, it is called confluent. Of these two 
varieties, the latter is necessarily more severe and dangerous than 
the former, in consequence of the great extent of tegumentary sur- 
face inflamed. During the various changes that the vesicles un- 
dergo, they are surrounded by small, inflamed areola?, which differ 
in appearance according to the number of the vesicles. In cases 
of the distinct form, in which the eruption is sparse, so that the 
pocks are widely separated, the areola? fade gradually into the 
natural colour of the skin, at the distance of a third or two-thirds 
of a line or more from the base of the vesicles, whilst in those in 
which the eruption is more abundant, they run together, so that 
the spaces between the pocks are of a more or less bright red 
colour. In confluent attacks, again, the areola? are more or less 
imperfect, according to the manner in *which the vesicles are 
grouped together. 

The change of the vesicles into pustules takes place generally 
from the fourth to the sixth day of the eruption. During this pro- 
cess the fluid of the pocks becomes more and more opaque, whitish, 
and at length assumes a yellowish colour, being in fact converted 
from serosity into pus. At the same time the pocks become larger, 
begin to distend, and as they approach complete maturation, gra- 
dually lose their umbilicated shape and become convex on the sur- 
face. The formation of the pustules follows the same course as 
did the vesicles, beginning on the face and extending thence 
to the neck, trunk and extremities. The areola? that have just 
been described as existing during the vesicular stage of the disease, 
continue during the early port of the stage of pustulation, but de- 



SYMPTOMS. 523 

cline towards its termination, assuming as they disappear a purple 
tint. The number of pustules is in proportion of course to that of 
the vesicles, but from the increase in size of the pocks during the 
changes from papules into vesicles and pustules, the eruption, when 
at its height, seems to be greatly more extensive than would have 
seemed probable at the beginning of the first stage. As a general 
rule the pocks are most numerous on the face, and after that part 
on the neck and limbs. On the trunk the eruption is always much 
less abundant than on other parts of the body, and even when con- 
fluent in the highest degree on the face and neck, it is generally 
so only in patches on the limbs, while it is distinct on the thorax 
and abdomen. 

Simultaneously with the eruption upon the skin, there occurs 
one also upon the mucous membranes, particularly those of the 
mouth, nasal passages, fauces, eyelids, and sometimes of the pre- 
puce and vulva. It begins with more or less vivid redness of the 
membrane followed by the production of little elevations, the real 
nature of which, whether papular or vesicular, does not seem to be 
clearly determined. About the second or third day these red ele- 
vations assume the appearance of small, whitish, rounded, not urn- 
bilicated pseudo-membranous points, which last generally about 
five days, and are then detached, leaving usually a little ulceration 
or erosion, which heals without leaving a cicatrix. 

A short time after the appearance of the pustules in the mouth 
and throat, a true inflammation of the mucous membrane of those 
parts take place. When the gums are inflamed they become 
swelled, red, and spongy, and are dotted over with white pseudo- 
membranous points of a rounded shape. Sometimes the velum 
pendulum, and more rarely the tongue, present the same white 
points, with redness and injection of the membrane between. In 
most of the cases there is also partial or general inflammation of 
the pharynx, which occurs subsequently to the formation of the 
variolous pustules. The existence of this inflammation is denoted 
by more or less severe sore throat, attended with difficulty of 
swallowing, and with swelling and tenderness of the sub-maxillary 
glands. When the mucous eruption extends to the larynx, as 
often happens, there is pain in that part ; the voice becomes hoarse 



524 SMALL-POX. 

or whispering, and there is hoarse, laryngeal, smothered cough. 
The pharyngo-laryngitis just described occurs generally between 
the third and sixth days of the eruption, and ceases about the 
eighth or thirteenth. In some instances it does not exist at all or 
to a very slight extent. 

During the eruption there is more or less inflammation and 
swelling of the subcutaneous cellular tissue, the degree of which 
depends on the extent of the eruption. The skin becomes tense, 
red, shining and elastic under the finger, and more or less hot and 
painful. The swelling is greatest upon the face, where it com- 
mences about the fourth or fifth day of the eruption, and goes on 
increasing for five or six days, occasioning much pain, stiffness, 
and inconvenience to the child. The swelling diminishes when 
desiccation begins, and ceases entirely as the latter is accom- 
plished. 

It is important to study carefully the general symptoms of the 
second stage. The fever which existed during the initial stage, 
generally continues during the first day or two or three days of 
the eruption. When, however, the papules are fully thrown out, 
the fever subsides or disappears entirely, so that the pulse falls 
from 100, 120, or 140 beats, to 100, 80, 76, or 74, and the heat 
of skin diminishes at the same time. The child remains without 
fever usually throughout the vesicular period of the eruption, that 
is to say, until the fourth, fifth, or sixth day ; during which time 
the appetite sometimes returns, sleep is tranquil and quiet, and the 
patient is in most respects well and comfortable. 

About the fifth or sixth day of the eruption, at which time the 
maturation of the pustules is nearly completed on the face, and 
that process is commencing on the extremities, a new fever, to 
which the technical term secondary fever is applied, makes its ap- 
pearance. The pulse rises again to 88, 100, 120, and 140, and 
becomes strong, hard, and full, whilst the skin is hot and dry. 
After continuing for some days the secondary fever diminishes 
when the suppuration is fully established, and disappears about the 
time that desiccation is nearly completed on the face, and has com- 
menced upon the limbs. It ceases generally, therefore, about the 
ninth or eleventh day, having lasted between four and six days. 



SYMPTOMS. 525 

This attack of fever is evidently the consequence of the suppura- 
tive stage of the disease, or of the conversion of the vesicles into 
pustules. 

Towards the termination of the second stage, at the very height 
of the disease, when the pustules begin to break and discharge 
their contents, the patient exhales a peculiar, disagreeable, fetid 
odour, which is somewhat characteristic of the disease. 

The third or declining stage, is that of the desiccation or dry- 
ing of the pustules and their desquamation. The desiccation com- 
mences generally between the sixth and ninth days, and termi- 
nates between the tenth and fourteenth. The formation of the 
crusts begins upon the face and extends thence to the neck and 
limbs. It does not reach the limbs usually until about two or four 
days after it had commenced on the face. The mode in which 
the drying of the pustules takes place is not the same in all. In 
some a dark point is formed in the centre which gradually extends 
and converts the whole pustule into a hard crust ; in others 
the whole surface dries at the same time ; whilst in others 
again, the epidermis gives way and allows the contained fluid to 
escape, which then hardens into yellowish, irregular crusts, which 
become brown before they fall off. Some of the pustules, particu- 
larly those upon the arms and legs, do not form scabs at all, but 
shrink away from the absorption of their fluid, leaving behind 
nothing but pellicles of cuticle which fall off by desquamation. 

The desquamation or falling of the crusts begins from the 
eleventh to the sixteenth, and ends somewhere between the nine- 
teenth, twenty-fifth, and even fortieth days of the eruption. When 
the scabs fall off the appearances presented by the skin beneath 
vary in different cases. In some a true ulceration and loss of sub- 
stance of the derm has taken place, which presents all the cha- 
racters of a suppurating ulcer when desquamation occurs early in 
the disease, or, when that process occurs at a later period, the 
ulcer is found to be dry and cicatrized. In both these forms of 
desquamation, the cicatrices form little pits or depressions, which 
remain during life. In other instances the fall of the scabs leaves 
red, excoriated surfaces on a level with the surrounding skin, which 
soon dry, leaving blotches of a reddish-brown colour, that do not 
disappear entirely for months. No cicatrices remain when des- 



526 SMALL-POX. 

quamation takes place in this manner. In a third series of cases 
the crusts do not fall until the surfaces beneath have entirely cica- 
trized, and the only traces left behind are more or less deeply 
tinted reddish spots, with occasional slight furfuraceous exfoliation 
of the cuticle, all of which disappear entirely after a time without 
leaving pits or cicatrices. 

To conclude the account of the symptoms of the disease, I have 
a few words to say in regard to the condition of some of the im- 
portant organs throughout the course of the malady. 

The tongue presents no appearances peculiar to the disease, 
other than the eruption already described. It is generally moist, 
more or less furred, and either pale or red in colour. The abdo- 
men usually remains soft and undistended, though in some instances 
it is slightly, tumid and heated, with occasional pains in the epigas- 
tric, umbilical, or iliac regions ; in simple cases, the latter symp- 
toms rarely last more than a short time, and when otherwise they 
are almost always the sign of some complication. The constipa- 
tion which exists during the initiatory stage generally continues 
throughout the disease, though in some instances a slight diarrhoea 
occurs about the end of the first or second week, after which the 
bowels return to their natural condition. If severe diarrhoea 
should make its appearance, it is almost always the sign of a dan- 
gerous complication. The nausea and vomiting which are so 
often present during the prodromic stage, cease after the appear- 
ance of the eruption, and recur only in rare cases, or in conse- 
quence of some complication. The appetite is almost always lost 
during the course of the disease, though it sometimes returns in 
the period between the termination of the initial and commence- 
ment of the secondary fever ; thirst is acute as a general rule, and 
more or less so, according to the violence of the fever. 

The strength of the child is not, as a general rule, greatly dimi- 
nished, except in severe and dangerous cases. Restlessness, irri- 
tability, crying, and delirium, which are of such frequent occur- 
rence in the febrile diseases of children, are not usually very 
strongly marked in regular cases of variola. They exist, but it is 
to a moderate extent only. In severe, irregular, confluent cases, 
on the contrary, restlessness, crying, and delirium, are present in 



SYMPTOMS — IRREGULARITIES. 527 

a very high degree, either towards the termination of the attack, 
or throughout its course, and they are then of very bad augury. 

I shall here conclude the history of the symptoms of the regular 
form of the disease. I have not attempted a separate account of 
the distinct and confluent cases, believing them to be merely diffe- 
rent degrees of the same affection ; the latter being much the most 
severe and dangerous, from its greater intensity, than the former. 
I will merely remark that all the symptoms are more severe in con- 
fluent cases, particularly the fever, and those which indicate dis- 
order of the nervous system. 

I shall proceed next to a description of some of the irregularities 
of the disease, or as expressed by some writers, of irregular or 
anormal variola. I would remark in the first place that a large 
number of the cases that have been called confluent, ought rather 
to be called irregular, since many of the symptoms detailed as 
belonging to that form of the affection, depend, not upon the con- 
fluent nature of the eruption, but upon the existence of some irre- 
gularities in its characters, entirely independent of confluence or 
running together of the pustules. 

The first or initial stage of irregular variola may be either 
longer or shorter than the regular form. As a general rule, the 
symptoms of this stage resemble very closely those of the regular 
form, when the attack occurs in a child previously in good health ; 
whilst in secondary attacks they present differences which are 
more or less strongly marked. The most important of these are 
the greater infrequency of headache, vomiting, and of the lumbar 
pains ; the presence of diarrhoea rather than constipation ; the 
greater frequency of sleeplessness, oppression, and restlessness; 
and, as a general rule, the earlier appearance of the eruption. 

The second or eruptive stage generally passes through its periods 
with much greater rapidity, so that the conversion of the papules 
into vesicles occurs as early as the first or second day, and that 
of the vesicles into pustules, between the second and fourth days. 
In some few cases, on the contrary, the eruption is retarded, and 
the papules may remain unchanged as late even as the fifth or 
sixth day. The progress of the eruption is so irregular some- 



528 SMALL -POX. 

times that there may exist, upon the same surface, papules, vesi- 
cles, pustules, and scabs. 

The appearances presented by the eruption often differ widely 
from those which have been traced as characteristic of the regular 
disease. The papules may be pale, irregular, uneven, and desti- 
tute of areola?, and when this happens, the vesicles and pustules 
which succeed usually present the same peculiarities. In other 
instances the papules and areolae are of a purple-red colour, and 
the vesicles, instead of being transparent or whitish, are also red- 
dish, and appear to be filled with a bloody serum. The pustules 
in these cases also contain a sanguinolent fluid, and when broken 
their contents escape, and form bloody scabs. In this variety of 
the disease, which is called hemorrhagic, the papules and vesicles 
are very small, are developed slowly, and remain flat and un- 
distended, as a general rule, whilst in a few cases, they are of a 
larger size, but remain almost always flattened in shape and un- 
filled. The scabs, when they form, are thin, soft, easily detached, 
and leave beneath bleeding surfaces and scarred pits. 

The fever of the initial stage rarely subsides in irregular vari- 
ola, upon the appearance of the eruption, as it does in the regular 
disease ; but, on the contrary, usually goes on augmenting. The 
distinction, therefore, into primary and secondary fever does not 
properly exist. Sometimes, however, a notable increase of fever 
does take place, at the period when the vesicular passes into the 
pustular stage of the eruption. The fever is usually more violent 
in the form of the disease under consideration, than in regular 
attacks, the pulse being full and large, and rising as high as 160. 
In fatal cases it becomes small towards the termination. The skin 
is generally very hot and dry. 

The appearances of the tongue, condition of the abdomen, appe- 
tite, thirst, and nervous symptoms, are of the same character as in 
the regular form, except that the signs which they present are 
more severe and unfavourable, particularly the delirium, agitation, 
and cries. 

Varioloid, or modified small-pox. — This is a term now usually 
applied to the modified form of the disease, as it occurs in indivi- 



SYMPTOMS. 529 

duals who have been vaccinated, or who have already had the 
natural or inoculated disease. 

The symptoms of this form of variola are, in general, the same 
as those of the regular disease, the only difference being in their 
greater mildness and shorter duration. The attack usually begins 
with slight fever, headache, languor, and sometimes constipation, 
which are followed, in two or three days, by the eruption. The 
vomiting, lumbar pains, and different nervous symptoms which 
exist in regular variola are not often present, or, if so, in a very 
slight degree. The eruption consists of papules like those of true 
small-pox, but usually few in number, and entirely distinct in their 
arrangement. The prodromic fever and other symptoms subside 
completely upon the appearance of the eruption, and the child often 
seems perfectly well. 

The progress and characters of the eruption are very similar to 
those of the regular form of the disease, with the exception that the 
changes are more rapidly effected, and, as a consequence, the 
duration of the attack rendered by so much shorter. The papules 
are converted into vesicles at a much earlier period, — as early as the 
first or second day. The vesicles soon assume a whitish, opaline 
appearance, become umbilicated, and in the course of the second 
or third day began to change into pustules. The suppurative 
stage of the eruption, or maturation, is seldom accompanied by the 
same marked secondary fever as in the regular disease. When it 
does take place, it is generally very moderate, consisting merely 
in slight acceleration of the pulse, and a little increased heat of 
I skin, and in one or two days disappears entirely. The pustules 
do not usually fill so well as in regular variola, and not unfre- 
I quently their contents are rather sero-purulent, than purulent in 
the proper sense of the term. The third stage occurs earlier, and 
goes through its periods more rapidly than in true small-pox ; de- 
siccation soon takes place, is speedily finished, and the falling of 
■ the scabs, which begins as early as the eighth day of the eruption, 
is usually completed about the twelfth or fourteenth. After de- 
squamation is completed, the only traces of the disease left are 
, reddish spots or blotches, which disappear after a time without 

45 



530 SMALL-POX. 

leaving cicatrices. The whole duration of the attack is generally 
from ten to twenty days. 

Complications. — The most frequent and important complica- 
tions of variola in children, are inflammations of the mucous mem- 
brane of the lower half of the intestinal tube, ophthalmia, otitis, and 
different hemorrhages. In a smaller number of cases, attacks of 
bronchitis, pneumonia, anasarca, articular inflammations, subcu- 
taneous abscesses, simple and pseudo-membranous coryza, angina, 
and laryngitis, and other eruptive diseases, occur at different pe- 
riods of the malady. 

Meningitis and encephalitis are very rare, so much so, that not 
a single instance occurred out of 112 fatal cases of the disease in 
the Children's Hospital, at Paris. 

It is impossible for me, for want of space, to attempt a descrip- 
tion of the various symptoms of the different complications just 
enumerated. Having mentioned the possibility, and probability 
of their occurrence, I must leave the reader with the advice al- 
ways to suspect the existence or approach of some one of them, 
when the symptoms, in any case, differ much from those which 
have been described as characteristic of the regular form. 

Anatomical Lesions.— The characteristic lesions of small-pox 
are a certain deteriorated state of the blood, congestion of all the 
organs, and the inflammation of the skin and mucous membranes 
constituting the eruption. The blood is found to be entirely liquid 
and serous, and of a dark colour ; or if coagula exist, they are 
small, soft, and very dark in colour. The exceptions to this rule 
are those in which some acute and severe inflammation exists, un- 
der which circumstances the dissolved state of the blood is less 
marked, and fully formed coagula are more abundant. The con- 
gestion referred to affects almost the whole system. The muscles 
are firm and of a deep red colour ; the membranes of the brain are 
strongly injected ; the sinuses filled with blood, and the cerebral 
substance presents numerous red points or dots. The vessels of 
the lungs contain a large quantity of blood, and the liver, spleen, 
and kidneys, are all deeply congested. 

The condition of the mucous membranes is important. The 
pharynx, larynx, and trachea, present the appearances of an erup- 



ANATOMICAL LESIONS. 531 

tion, or of simple inflammation without eruption. The eruption 
exists under the aspect of small, circular, thin, and whitish pseudo- 
membranous points, scattered over the mucous tissue, and slightly 
adherent to it, beneath which that tissue is often observed to be 
red and inflamed. At a more advanced degree, and in severer 
cases, the false membranes have disappeared, and in their places 
we find circular ulcerations, which are either superficial, or pene- 
trate the tissue of the mucous coat and rest upon the muscular, 
or even pierce that and reach to the cartilaginous tissue beneath. 
In addition to these lesions are found inflammation of the mucous 
tissue with its consequences, redness, softening, thickening, and 
extensive deposits of false membranes, quite distinct from the 
appearances above described as characteristic of the eruption upon 
these tissues. 

It has been a contested point whether a true vesicular or pustu- 
lar eruption ever exists upon the mucous lining of the stomach 
and intestines. The general opinion appears now to be, however, 
that the changes observed in these organs cannot be ascribed to 
the formation either of vesicles or pustules. The appearances that 
have led some observers to consider them as the result of a proper 
eruption are the following. The follicles at the commencement 
and termination of the small intestines, and in rarer cases, of the 
large intestine also, present an abnormal degree of development, 
appearing in the form of small, hemispherical or pointed, and some- 
times flattened projections, on which there often exists a dark, 
and sometimes depressed central point. At the same time the 
plaques of Peyer are often enlarged, more projecting than usual, 
softened and red. 

The anatomy of the variolous pock is important and interesting. 
When a vesicle is opened soon after its formation, it is found to 
contain nothing but a little serosity which is perfectly limpid and 
alkaline, while the skin beneath is red, softened, and moist. The 
umbilicated character depends on a filiform adhesion between the 
centre of the pock and the surface of the skin beneath. This ad- 
hesion is broken, when, at a later period, the pustule becomes glo- 
bose in shape. About the period of the conversion of the vesicles 
into pustules, or very soon after the formation of the latter, the 
cavity of the pock will be found to contain a false membrane, 



532 SMALL-POX. 

which is of an opaque white colour, soft and friable in its texture, 
and seated upon the derm in small isolated points. After a time 
these points enlarge, and meeting, unite, and form a soft pseudo- 
membranous disc, uneven upon its surface, and which either fills 
the pock completely, or is covered at first with serosity and after- 
wards with pus. This false membrane is secreted originally by 
the true skin. At a somewhat later period it forms a strong ad- 
hesion to the inner surface of the cuticle, while still later in the 
progress of the pock, it becomes detached from the cuticle, and 
remains loose and free in the cavity of the pustule, surrounded by 
the fluid contents of the latter. 

Diagnosis. — The most important point in the diagnosis of 
variola, is its recognition during the prodromic or initial stage. 
The only symptoms that can be depended upon as indicating with 
any considerable probability the approach of the disease, are the 
simultaneous existence of fever, constipation, bilious vomiting, and 
severe pains in the back, in a child not previously vaccinated, and 
in whom there is no more probable mode of accounting for the 
symptoms enumerated. If, in addition to these circumstances, the 
disease be extensively prevalent at the time, and still more, if the 
child has been exposed to the contagion of the malady, the diag- 
nosis becomes almost certain. After the eruption makes its ap- 
pearance the diagnosis is seldom doubtful. There may be some 
doubt for the first k\v hours, but soon the enlargement of the 
papules, the subsidence of the fever, and then the change into 
vesicles, remove all uncertainty as to its real nature. 

Prognosis. — The prognosis of variola must depend very much 
upon the form which it assumes. The regular form of the disease 
generally terminates favourably unless some complication happens 
to occur, in which case the danger to life is greatly augmented. 
It is generally stated also that the distinct is much more favourable 
than the confluent form of the affection. Rilliet and Barthez say, 
however, that all the cases of the simple (uncomplicated) confluent 
disease which they met with recovered. Irregular variola, on the 
contrary, is fatal in a large proportion of the cases. The authors 
just quoted state that only three recovered out of thirty-nine that 
came under their observation. 



PROGNOSIS TREATMENT. 533 

The varioloid disease is very rarely fatal. 

The favourable symptoms in any case of variola are the occur- 
rence of the disease in children previously in good health ; the 
absence of any violent nervous symptoms during the initial stage ; 
a proper duration of the first stage; and subsidence of the fever 
after the appearance of the eruption. When, in addition to these 
circumstances, the secondary fever is not too violent, and no compli- 
cation arises, there is but little doubt of the recovery of the patient. 

The unfavourable symptoms are the existence of severe nervous 
symptoms during the first stage ; the occurrence of a thick and abun- 
dant eruption upon the face, indicating a probably confluent case; 
continuation of the fever after the appearance of the eruption, or a 
merely slight subsidence of it ; delirium and other nervous symp- 
toms during the secondary fever ; any irregularity in the appear- 
ance of the eruption, as paleness instead of the usual red colour, 
a livid or purplish colour of the pustule, imperfect development of 
the pocks, or their sudden shrinking without diminution of the 
general symptoms. It is scarcely necessary to say that many of 
these symptoms are indicative of the existence or threatened produc- 
tion of some complication, upon the nature of which must depend, 
after all, in a great measure, our prognosis. The complications 
most apt to occur have already been considered in a previous 
article. 

Treatment. — I shall begin my remarks upon the treatment of 
the disease with the following quotation from Dr. Gregory ( Tivee- 
die's Lib. of Pract. Med. Am. ed., vol. i, p. 332.) " Before enter- 
ing on the curative treatment of small-pox, therefore, it will be 
proper to recall to remembrance the peculiar nature of the disorder. 
It is a fever which relieves itself by superficial eruption. That 
eruption, even when too copious, cannot be diminished or checked 
in its progress by any effort of art ; when moderate it requires not 

the interference of the physician." " Heroic remedies are 

here wholly inapplicable and the great object of art is simply to 
place the system under the most favourable circumstances for 
effecting what the old physicians called the concoction and elimina- 
tion of the morbid humours." 

The treatment of simple, uncomplicated small-pox, ought, unless 

45* 



534 SMALL- POX. 

the attack be confluent, to be of the mildest character. Rest in bed, 
low diet, cooling drinks, some gentle laxative, an occasional foot- 
bath during the first stage, are all that is required in most cases. 
When, however, the fever is considerable, and the child restless 
and complaining, we may add to these means some diaphoretic, as 
the saline or effervescing mixture, with small doses of sweet spirits 
of nitre, or spiritus Mindereri ; or we may direct very minute doses 
of tartar emetic, from ^q to ^ of a grain for a child four years old, 
to be repeated every hour or two hours, or from one to three drops 
of the antimonial wine, with five or ten of sweet nitre, for a child of 
the same age, every two hours. Should either of these produce 
much vomiting, or any action upon the bowels, they must be sus- 
pended. If the fever be violent, either during the initial stage, or 
later in the attack, with a full strong pulse, great heat and swelling 
of the skin, severe headache, or signs of congestion of the internal 
organs, it will be proper to bleed, either generally or locally. 
General bleeding is preferable as a general rule, unless there be 
some local determination, in which event local depletion may be 
substituted ; but even here venesection had better be resorted to in 
many cases, as more effectual and less annoying to the child than 
either cups or leeches. The amount of blood to be taken must 
depend on the age, constitution, and present strength of the patient. 
Having regard to the nature of the disease, and its future course, it 
is best always to bleed less freely than in acute local affections. 
Under the circumstances just supposed, we are advised by Dr. 
Gregory to make use of purgative medicines every day. Rilliet 
and Barthez, on the contrary, oppose their employment as likely 
to occasion some serious intestinal lesion, and advise the use merely 
of mild laxatives or enemata to an extent sufficient to keep the 
bowels soluble. 

When the eruption comes out slowly and tardily, remaining for 
an unusual length of time in the papular state, or forming small 
and flattened vesicles, the pulse being at the same time frequent 
and undeveloped, we may hasten its appearance by the use of some 
warm diaphoretic infusion, as balm or sweet- marjoram tea, with 
spiritus Mindereri, by putting additional covering upon the child, 



TREATMENT. 535 

and by the employment of warm baths, of mustard pediluvia, and 
of mustard poultices to the epigastrium. 

Dr. Gregory advises the employment of nourishing diet and 
gently cordial medicines, when the pustulation is profuse over the 
whole body. When the period of secondary fever is accompanied 
with symptoms of extreme debility, as feeble pulse, brownish 
tongue, coldness of the skin, typhoid expression of the countenance, 
subsultus tendinum, and general tremors, the treatment must con- 
sist in the use of nutritious diet, and of stimulants, as wine and 
brandy, carbonate of ammonia and quinine, or compound infusion 
of cinchona. Camphor, administered in doses sufficient to allay 
the disturbance of the nervous system, is an excellent adjuvant to 
the stimulants mentioned. In cases of hemorrhagic variola, the 
above stimulating treatment must be employed, in connexion with 
the use of bark or quinine in large doses, and of some of the mineral 
acids. The quinine ought to be given in doses of a grain every 
hour, so that from six to ten grains may be taken every day. 

Treatment of the complications. — It may be stated, in general 
terms, that the treatment for the different complications is the same as 
that which is proper for the diseases constituting them when they exist 
as idiopathic affections, with, however, the modifications rendered 
necessary by the nature of the general disorder. Thus, acute in- 
flammation must be treated by antiphlogistics, used, however, with 
great care and reserve, in consideration of the length of time during 
which the patient must be sick, and the necessity there is for pre- 
serving his strength and maintaining a proper crasis of the blood, 
in order that he may be enabled to carry on the various changes in 
the disease requisite to effect a return to health. These remarks 
apply particularly to angina, laryngitis, bronchitis, pneumonia, en- 
tero-colitis, and ophthalmia. When the acute affection is only of 
moderate extent and severity, it is best, except in the case of 
intestinal inflammations, to depend upon a moderate employment 
of cathartics, of small doses of the antimonials in conjunction with 
diaphoretics, of gentle counter-irritants, and, when necessary, of 
small detractions of blood by leeches. Nevertheless, it is un- 
doubtedly proper, when the acute disease is severe and extensive, 
the child strong and vigorous in constitution and present health, 



536 SMALL-POX. 

the pulse full and strong, and the skin hot and red, to make use of 
general bleeding. 

The treatment of the ophthalmia which so often threatens, and 
sometimes occasions great or irreparable injury to the eye, must 
be of the kind just recommended. In this complication the local 
treatment is exceedingly important. When ulcerations occur upon 
the cornea, they ought to be touched if this be practicable, with 
solid nitrate of silver, sharpened to a point, or with a fine camel's 
hair pencil which has been moistened and rubbed over the caustic 
to insure a caustic solution. When it is impossible to apply the 
solid caustic or the brush, we must resort to some collyrium. 
This may consist of a solution of nitrate of silver, a grain to the 
ounce, or of one or two grains of sulphate of zinc, with twenty 
or thirty drops of wine of opium, in an ounce of rose water, of 
either of which two or three drops are to be introduced into the 
eye morning and evening. When the first solution is used, its 
strength should be increased after a few days to a grain and a half, 
two grains, or even more, to the ounce of water. 

The complication of entero-colitis must be treated by the most 
careful attention to diet, the use of warm poultices to the abdomen, 
of emollient and anodyne injections, the internal administration of 
astringents and small doses of opiates, and when absolutely neces- 
sary, by small detractions of blood by leeches. When the diar- 
rhoea is severe, and the stools mucous or bloody, we may use with 
advantage the nitrate of silver internally or by enema, in the 
manner directed in the article upon entero-colitis. 

The treatment of the convalescence from variola is important. 
The same rules apply to it as to other infantile and children's 
diseases. 

Before terminating my remarks upon the subject of small-pox, 
it will be proper to give some account of the treatment of the 
eruption which has been recommended and practised, with a view 
to. prevent the scarring and disfiguration which so often result 
from the ravages of the disease. Of the different means which 
have been employed with this view, there are two which are 
almost exclusively relied upon at present. One is to cauterize the 
pustules with nitrate of silver, and the other to make a mercurial 



TREATMENT. 537 

application upon the part where it is desirable to cause the abortion 
of the eruption. The cauterization has been performed in two 
modes; by the application of the caustic to each pustule separately, 
or to masses of the eruption. It appears, however, that the first 
named method is much the most preferable. To succeed per- 
fectly, it is necessary to touch the derm forming the base of the 
pustule, so that the best plan is to remove or lift up a portion of 
the top of the vesicle with a lancet, and then to introduce into its 
interior the sharpened point of a stick of caustic. This operation 
is only certainly successful when performed on the first or second 
day of the eruption, though Rilliet and Barthez have known it to 
answer as late as the third and fourth, or even fifth day. The 
process of cauterization is productive of acute pain, but does not 
increase the local inflammation, according to the authors just 
quoted, at least when applied to a small number of the pocks. 
They state that when applied to the pustules seated upon the 
edges of the eyelids, it is almost incredible to behold how great is 
the diminution of the oedema of those parts in a single day. The 
conclusion of these gentlemen is, that it is certain that individual 
cauterization of the pustules with nitrate of silver causes them, as 
well as the surrounding tumefaction, to abort, and prevents them 
from leaving cicatrices. 

The other method which has been employed to cause the abor- 
tion of the pustules, and thus prevent disfiguration is, as has been 
stated, the application of some mercurial preparation. The effects 
of this treatment are said to be an almost certain arrest of the deve- 
lopment of the eruption, when it is used from the first or second, or 
not after the third day ; the vesicles and pustules remaining small 
and isolated, and not assuming, or soon losing, the umbilicated 
character. When applied early, while there are as yet but few 
vesicles formed, it prevents the development of new ones, and 
diminishes the accompanying swelling and soreness. When the 
application is removed on the seventh or eighth day, it is found 
that desiccation has occurred imperfectly, the surface presenting 
small soft scabs, or little whitish, soft elevations, consisting of the 
pseudo-membranous substance situated between the true skin and 
the new epidermis, the old cuticle having generally peeled^ off with 



538 SMALL- POX. 

the plaster. In some places a light rose-coloured surface alone 
remains. 

In regard to the success of this treatment in preventing dis- 
figuration, I may quote the statement of Rilliet and Barthez, that 
none of the patients upon whom they saw it tried, presented any 
cicatrices, though several had had confluent-pox which pursued its 
usual course on the parts not covered by the application. Dr. 
Stewardson, of this city, made a considerable number of trials of 
this treatment at the small-pox hospital of this city in 1841-42. 
He gives his conclusions in the following words, (Am. Journ. 
Med. Sc. January, 1843, p. 86-7.) " From these experiments, it 
seems pretty evident that the mercurial plaster has a decided in- 
fluence upon the small-pox pustules, preventing more or less com- 
pletely their perfect maturation, and diminishing the concomitant 
swelling and soreness, the process of desiccation being completed 
without the formation of thick scabs, and the resulting cicatrices 
less marked than when the process of suppuration was left to 

pursue its natural course." " That by its use pitting 

may be entirely prevented, or the mortality from small-pox 
materially lessened, seems to me very doubtful, although had all 
the precautions above-mentioned been taken, it is not improbable 
that the effects would have been still more decided." 

The use of the mercurial application is attended with some in- 
convenience. In the first place it is difficult to keep it accurately 
applied, particularly in children, in consequence of the unpleasant 
sensations it occasions. In the second place, it not very unfre- 
quently, according to Rilliet and Rarthez, produces an eruption of 
hydrargyriasis, or mercurial roseola, in about eight or fourteen 
days after the variolous eruption, or four or ten after the applica- 
tion of the remedy. Rayer, however, states this effect to be a 
rare one. 

Dr. Stewardson says that he thinks no apprehension need be 
felt as to constitutional affection from the mercury, for scarcely 
ever were the gums even touched. I may state, however, that 
when in Paris, in 1840, I saw this effect produced in a young girl 
at the Children's Hospital. 

The ^method of its application is different in different hands. 



TREATMENT. 539 

The French generally employ the emplastrum de Vigo cum mer- 
curio. Dr. Stewardson prefers the strong mercurial ointment, 
either pure or rubbed down with an equal bulk of lard, spread 
upon a piece of thick muslin. The muslin is to be cut into the 
shape of a mask, with apertures for the eyes, nose, and mouth. 
It is secured upon the face by means of strings attached to its 
margin, and tied across the back of the head and neck. It is im- 
portant always for the success of the measure, that the application 
should be kept in close contact with the skin. To insure this, Dr. 
S. employed a separate piece of muslin for the nose, which is the 
part most difficult to fit. With the same view the French authors 
recommend that the plaster should be cut into pieces to suit the 
different portions of the face, making one for the forehead, and 
others for the cheeks, sides and back of the nose, and upper 
and lower lips. Any spaces that may remain are to be covered 
with other portions of the plaster, and the whole secured with 
strips of diachylon. On account of the difficulty of applying the 
mercurial plaster, the following ointment was composed by the 
apothecary of the Children's Hospital at Paris, and has been found 
to answer very well : Mercurial ointment 24 parts ; yellow wax 
1 parts ; black pitch 6 parts. — Mix. 

The application ought to be confined to the face, as that is the 
part which it is most important to save from disfiguration, and as 
it is better not to use it upon a larger surface than necessary, lest 
it might occasion the mercurial roseola, or possibly salivation. 
As a general rule, four or five days are sufficient, according to 
Guersent and Blache, to leave it in contact with the skin, in order 
to avoid the bad effects just referred to. 



ARTICLE IV. 

REVACCINATION. 

I deem it unnecessary, in consequence of my restricted limits, 
and particularly as the subject may be found fully discussed in 
any of the standard works on medicine, to attempt a description of 



540 REVACCINATION. 

either the history, phenomena, or mode of performance of vacci- 
nation. I desire merely to make a few remarks upon the subject 
of revaccination, a matter about which there is much difference of 
opinion in this country, and the exceeding importance of which is 
not, I think, properly appreciated by some practitioners, and still 
less by a considerable portion of the public. 

It seems to me that the diminution of the protective power of 
vaccination by the progress of time has been most positively and 
clearly shown by the observations of latter years. That this is 
true, is proved, I think, by the fact that almost all recent writers 
on vaccination recommend a recourse to revaccination some years 
after the first operation. With the view of bringing this matter 
fairly before the reader, I will quote the opinions expressed by 
some of the leading authorities of the day. 

Dr. Gregory (Loc. cit. p. 346) says : " The practice may be 
recommended for its safety, even if it be much less serviceable 
than the Germans contend for. We have sufficient facts before us 
to state that it need never be recommended prior to the tenth year 
of life, and that the age best fitted for it is from the period of 
puberty to that of confirmed manhood." Guersent and Blache 
(Diet, de Med. deux. ed. t. xxx, p. 435) have revoked their first 
opinion that revaccination was unnecessary, and state that they 
now believe firmly " that its protective power becomes enfeebled 
and does not preserve the individual from contracting variola in a 
more or less favourably modified form ; and that in consequence 
revaccination ought to be zealously recommended and propagated." 
The Academy of Medicine of Paris, consulted by government 
upon this question, some years since, determined that revaccina- 
tion was unnecessary. In February, 1845, however, the same 
learned body, after reconsideration of the matter, arrived at diffe- 
rent conclusions. Two of these I shall quote. " Revaccination is 
the only method of proof which science possesses of distinguishing 
persons who have been definitely protected by vaccination from 
those who are so only in various degrees." 

" The trial by revaccination does not constitute a certain proof 
that those of the vaccinated in whom it succeeds were liable to 
contract variola, but only a tolerably strong presumption that it 



REVACCINATION. 541 

was particularly amongst them that the disease was apt to occur. 
In ordinary periods revaccination ought to be performed after the 
fourteenth year of life ; when the disease is epidemic, it is prudent 
to resort to it earlier." (Guersent and Blache, Loc. cit. p. 436.) 

Rilliet and Barthez say (t. ii, p. 538) : " The diminution of the 
protective power of vaccination, after a certain number of years, 
seems to be positively proved, but it is proved also that this dimi- 
nution is almost nothing during the period of life which concerns 
us." Dr. Condie says (Bis. of Children, 2d ed. p. 466) : " If, 
therefore, the facts upon record are perfectly accurate, and there 
is no reason for suspecting them to be otherwise, they afford con- 
clusive evidence of the necessity and importance of revaccination, 
in all cases in which persons are liable to be exposed to the infec- 
tion of small-pox." It is scarcely necessary to remark that all 
individuals residing in a district in which the disease is prevailing, 
are exposed to the infection, and, therefore, according to the above 
quotation, all ought to be revaccinated, which is what I am seeking 
to establish. Dr. Geo. B. Wood, to whose work on medicine I 
would refer the reader for a very accurate and full account of 
vaccination and revaccination, terminates his remarks on the latter 
subject with the following paragraph. " In concluding the subject, 
I would again strongly urge the propriety of universal revaccina- 
tion, as the means not only of promoting the comfort and possi- 
bly of saving the life of the individual, but also of preventing the 
spread of small-pox, and of ultimately eradicating it, if not from 
the globe, at least from extensive communities." 

I might quote, in further proof of the propriety and necessity of 
revaccination, many other evidences emanating from various 
sources, but with the following short account of rny own expe- 
rience in regard to it, I shall bring my remarks to a close. In the 
year 1845 I revaccinated 63 persons, of whom 9 had the disease 
with every appearance of regularity, that is to say, the puncture 
did not become irritated until the third or fourth day, the vesicle 
was perfect on the ninth, with the umbilicated centre, hard base, 
and scarlet areola, and after that period the inflammation subsided 
rapidly. Of these 9 all but one had characteristic cicatrices of 
previous vaccinations on the arm. The ninth was doubtful, but the 

46 



5 42 RE VACCINATION. 

individual insisted that he had been properly vaccinated. Of the 
remaining 54 cases, the great majority presented more or less 
strongly marked signs of the disease. In nearly all a yellowish 
pustule was formed some time during the second day, which 
was surrounded by an irregular patch of redness of small extent, 
presenting often a dotted or marbled look. In some the appear- 
ances promised a regular vaccine vesicle for several days, but ter- 
minated suddenly by the drying up of the vesicle, and the forma- 
tion of an ill-shaped acuminated scab, which soon fell off, leaving 
a slight scar quite different from that of a primary vaccination. 

The only remaining point for consideration is the period of life 
at which revaccination ought to be performed. The prevailing 
opinion seems to be that somewhere about puberty is the most 
suitable time, unless in the cases of children exposed immediately 
to the infection of the disease, when it may and ought to be re- 
sorted to at a much earlier period. 



CLASS V. 

WORMS IN THE ALIMENTARY CANAL. 

GENERAL REMARKS. 

There are five different species of worms found in the alimentary 
canal. They are the Ascaris lumbricoides, or round worm ; Ascaris 
vermicularis, thread-worm, seat-worm, or as it is popularly called, 
ascarides ; Tricocephalus dispar, or long thread- worm ; Tsenia so- 
lium, common tape-worm, or long tape-worm ; and the Bothrioce- 
phalus latus, taenia lata or broad tape- worm. 

I shall not attempt to discuss the question of the mode of origin 
of human entozoa, about which much difference of opinion still 
prevails, some asserting that their ova or germs are introduced 
from the exterior, while others, embarrassed by the difficulty of 
accounting for their existence in organs enclosed in shut cavities, 
advocate the opinion that they are the result of spontaneous 
generation. 

I shall give a short description of each of the intestinal entozoa, 
in order that they may be readily distinguished, but will treat of 
the causes, symptoms, and treatment only of the two first, inas- 
much as the tsenias very rarely exist during infancy or childhood, 
and the tricocephalus is much less frequent than the round and 
seat-worms, and gives rise to symptoms of the same kind as the 
former. 

Description. — The Ascaris lumbricoides, or, as it is commonly 
called, lumbricoides, lumbricus, or round worm, is shaped not un- 
like the common earth-worm, having a cylindrical body, which is 
attenuated towards either extremity, but particularly the anterior. 
It varies in length generally between six and twelve inches, and is 
usually about two or three lines in thickness. The young worm, 



544 worms. 

about an inch and a half long, is rarely met with. The head 
of the animal is at the smallest extremity, and may be distin- 
guished by a circular depression, around which may be seen three 
tubercles. When recently voided, the worms are somewhat trans- 
parent, so that the viscera may sometimes be seen through the 
parietes. The integument is marked by circular fibres, and by 
four lines extending at equal distances from the head to the tail, 
the former of which indicate the course of the muscles, while the 
latter indicate that of the vessels and nerves. 

The colour of the worm is whitish, yellowish, or of a more or 
less deep rosy tint, according to the nature of the aliment they con- 
tain ; they are, as already stated, somewhat transparent when first 
voided. The alimentary canal, which may be distinguished by its 
brownish colour, terminates by a transverse opening or anus, 
situated on the inferior surface of the animal, just in front of its 
posterior extremity. 

The two sexes are in different individuals. The male may be 
known by its tail, which is shortly curved, while that of the female 
is straighter and thicker. The genitals of the male consist of a 
double penis which may sometimes be seen to protrude just in 
front of the caudal extremity ; those of the female may be distin- 
guished by the vulva, seated at a constricted point of the body, 
about a third of the distance from the head to the tail. The male 
is smaller and much less abundant than the female. 

The Ascaris or Ozyuris vetmicularis, thread-worm, seat-worm, 
or maw-worm, is the smallest of the intestinal worms, and is gene- 
rally distinguished in popular language by the title of ascarides. 
The sexes are in separate individuals. 

The male is generally about two lines in length ; its body is 
elastic, of a whitish colour, very slender, and looks not unlike a 
piece of cotton thread, whence one of its names was derived. The 
female is larger than the male, reaching a length of four or five 
lines. The anterior part of the body is of the same shape in both 
sexes. It is obtuse, and surrounded by a transparent membrane, 
through which may be seen a straight tube, forming a kind of 
bladder, which is the oesophagus, and which terminates in a 
globular stomach. The head is provided with three tubercles, as 



DESCRIPTION. 545 

in the lumbricoides. The intestinal tube in the male continues the 
whole length of the body, which becomes somewhat thicker to- 
wards the end, and is arranged into a spiral shape at the tail. The 
body of the female is shaped like that of the male as far back as 
the stomach, and increases in size in the first third of its length, 
after which it diminishes, and becomes so small at the end as to 
be seen with difficulty by the naked eye. 

The Tricocephalus dispar or long thread- worm is generally 
about an inch and a half or two inches long, and consists, as it 
were, of two portions, of which the anterior, constituting about 
two-thirds of the length, is exceedingly slender, scarcely thicker 
than a horse-hair, while the posterior third suddenly swells out so 
as to become much thicker and larger. The sexes are in different 
individuals. The worm is provided with an alimentary canal, 
which, commencing at an orbicular mouth placed in the small 
extremity, runs through the animal to the anus, placed at the 
caudal extremity. The male is smaller than the female, and is, 
usually, found convoluted. This worm is met with chiefly in the 
caecum and colon, particularly the former. It usually exists in 
very small numbers, and often but a single one is found. The 
symptoms which it occasions are the same as those produced by 
the lumbricoides. 

The Taenia solium, common or long tape-worm, as well as the 
Taenia lata are of rare occurrence in children. Of 206 cases ob- 
served by M. Wavruch, only twenty-two occurred in subjects un- 
der fifteen years of age, and of them the youngest was three years 
and a half old. [Bib. du Med. Prat. t. v, p. 626.) These worms 
have however been met with at an earlier age, but as they are 
rare, I deem it unnecessary to do more than describe their appear- 
ances, in order that the reader may be able to distinguish between 
them and the varieties which generally exist in children, the Asca- 
ris lumbricoides, and vermicularis. For a full account of the 
symptoms produced by the two varieties of the taenia, and their 
treatment, the reader is referred to any of the standard works on 
the practice of medicine. 

The Tcenia solium is usually of a whitish colour, flat in form, 
and varies in length from five to ten feet, its ordinary length, to 

46* 



546 worms. 

sixty, or even, according to the assertion of some writers, upwaids 
of a hundred. It is uneven in shape, being thick and rounded be- 
hind, and measuring three or four lines at its widest part, while it 
tapers gradually towards the anterior extremity, where it becomes 
slender and thread-like. The head is minute in size, and flattish 
in shape, with a projecting papilla in the centre, furnished with a 
double circle of hooks, and surrounded by four cylindrical aper- 
tures, which seem to be the mouths of the animal. The body is 
composed of numerous segments, which are longer than broad at 
the posterior part of the worm, and resemble, when separated, the 
seeds of a gourd, and have hence been called cucurbitani. In this 
worm the two sexes exist in the same individual. 

The Bothriocephalus lotus, Tcenia lata, or broad tape-worm is 
long and flat like the preceding variety, but it is generally thinner 
and broader, measuring from four to ten lines in breadth. It 
sometimes attains, like the common tape-worm, to a very great 
length. It is usually of a dirty-white colour, and rather less 
opaque than the Taenia solium. It is distinguished also, says Dr. 
Wood, from the other taenia, by the shape of the segments, which 
are broader than they are long ; by the form of the head, which is 
small, elongated, without spines, and divided into two lobes by a 
longitudinal fossa on each side ; and by having, instead of the four 
mouths of the taenia, a single minute pore in the centre between 
the fossae, or else two pores, one at the extremity of each lobe. 

The frequency of intestinal worms, and their importance as a 
cause of disease, have certainly been, and are still by many 
physicians, and especially by the public, very greatly exaggerated. 
There can be no doubt that they do, when they exist in large 
quantities, and particularly in certain countries, give rise to great 
disturbance of the digestive organs, and even occasion death ; but 
such instances are, it seems to me, extremely rare in this city at 
least. I am quite sure that I have never as yet met with a case 
in my own experience, in which the constitution was at all 
seriously endangered by their existence, — though I have seen 
numerous instances in which slight disorders of the digestive 
apparatus, and various nervous symptoms, generally of very 
moderate severity, have disappeared after the administration of 



FREQUENCY AND IMPORTANCE. 547 

anthelmintics, sometimes followed, and in an equal number of 
cases probably, not followed, by the expulsion of worms. 

To show the truth of the above remarks, as to the impor- 
tance of worms as a cause of disease, I make the following 
quotations. Dr. Rush [Med. Inquiries and Observations, vol. 
i, p. 205), remarks : " When we consider how universally 
worms are found in all young animals, and how frequently 
they exist in the human body, without producing disease of 
any kind, it is natural to conclude, that they serve some useful 
and necessary purposes in the animal economy." M. Guersent 
says, [Diet, de Med. t. xxx, 669) : " It has always been the 
custom to assign to entozoa much too important an influence upon 
the diseases of childhood. In proportion as this part of pathology 
is perfected, it becomes evident that the greater number of children 
dying after having discharged worms, or even while having them 
still, are affected with acute or chronic diseases, which leave after 
death incontestable traces of their effects, and which are of them- 
selves necessarily fatal." M. Barrier (JSlo.l de VEnf. t. ii, p. 100), 
quotes M. Trousseau as making the following remarks. " For 
sixteen years we have not met with a single child who has pre- 
sented any verminous symptoms ; never or almost never does a 
child born and reared in Paris discharge worms, while just the 

contrary is true as to the provinces Young 

children, to be sure, are sometimes met with in our hospitals, who 
discharge worms, but they are those who have been born in the 
country, and have lived in the capital only for a short time." Dr. 
Condie, [Dis. of Child. '2d ed. p. 226,) remarks : " Worms are 
of very common occurrence in the intestines of children, and may 
unquestionably, under certain circumstances, become a cause of 
servere irritation ; — but much less frequently than is generally 
supposed." 

I believe we may conclude, therefore, that though these para- 
sites are of very common occurrence, and productive of grave 
disorders in some countries, they are rarely met with in quantities 
sufficient to do serious injury to the health, in other places, as for 
instance, Paris, and probably in this country, or at least in the 
northern parts of it. 

That intestinal worms do, however, not unfrequently in some 



548 ASCARIS LUMBRICOIDES. 

countries, and occasionally in all, produce dangerous and even 
fatal disturbances of the health, cannot be doubted after careful 
perusal of the evidence brought forward by different authorities. 
M. Guersent, amongst others, remarks (Loc. cit. p. 670): " It is 
nevertheless incontestable, that the development of these animals 
in the gastro-intestinal and abdominal cavities do sometimes give 
rise to very varied morbid phenomena, which are in some in- 
stances grave enough to cause death." Nevertheless, I am dis- 
posed to believe, as stated above, that fatal, or even dangerous 
results from the existence of these parasites, are of rare occurrence 
in this city, and probably throughout our northern states. Dr. 
Dewees, however, mentions several cases in which they produced 
alarming symptoms, and one in particular (Dis. of Child, p. 492), 
in which the subject, a child twenty months old, was extremely 
emaciated, and whose abdomen was " enormously distended, and 
semi-transparent," who i*ecovered rapidly after ninety-six lum- 
bricoides, from six to ten inches long each, had been expelled under 
the use of pink-root in infusion. 



ARTICLE I. 

ASCARIS LUMBRICOIDES. 

The descrijotioji of this worm has already been given at 
page 543. 

Causes. — Under this head I shall not pretend to consider the 
question of the origin of worms, but only the causes which pre- 
dispose to their production, or favour their growth. 

Age has no doubt a considerable influence upon the predispo- 
sition to lumbricoides. According to M. Guersent (Loc. cit. p. 
685), infants at the breast under six months of age are very 
rarely affected with them. Instances occasionally occur, but are 
altogether exceptions to the general rule. Above six months of 
age, they begin to be met with, but still very rarely, so that 
scarcely one or two will be found in several hundred children of a 
very early age ; while from three to ten years of age they will be 



CAUSES SEAT NUMBER. 549 

observed in about a twentieth, or in some seasons perhaps in 
a larger proportion. M. Valleix states that he has never met 
with them in new-born children. Dr. Dewees says (Loc. cit. p. 
481), that he has never seen worms in children under ten months 
old ; and only two instances at that age. I do not recollect myself 
ever to have seen them in subjects younger than eighteen months, 
and very rarely in those under three or four years. 

There can be little doubt that the disposition to worms is 
hereditary in some families. It is generally believed that the 
species under consideration is more common in girls than boys ; 
that it is most common in children of lymphatic and scrofulous 
constitution ; and that a too exclusively vegetable or milk diet, and 
an abuse of fruits, strongly predispose to their production. The 
habitation of a cold and damp, or warm and damp climate, and 
the seasons of summer and autumn, are supposed by many also to 
favour their production and growth. It is a general belief, and I 
should suppose from personal experience, a well-founded one, that 
a feeble and disordered state of the digestive function from any 
cause, often acts as a predisposing cause of worms, and particu- 
larly of lumbricoides. 

Seat. — The small intestine is in a very large majority of the 
cases the seat of the ascaris lumbricoides. They are met with, 
however, in other parts of the digestive tube, particularly the 
stomach and large intestine, and more rarely in the oesophagus or 
pharynx. In some instances they are found to have migrated to 
other organs, as to the liver, gall-bladder, and in still rarer cases, 
they have passed into the peritoneal cavity, bladder, larynx, trachea, 
bronchia, and even into the nasal passages and frontal sinuses. 
They have also been met with occasionally in the walls of the 
abdomen, forming verminous abscesses, whence they have escaped 
on the opening of the abscess. 

The number of ascarides is exceedingly variable ; there may 
be only two or three, ten or twenty, or several hundred. When 
very numerous, they are apt to be rolled or twisted into knots or 
balls, which have been seen as large as the fist, so as to block up 
completely the canal of the intestine. In a case cited by Rilliet 
and Barthez, from M. Daquin, the duodenum was so filled with 



550 ASCARIS LUMERICOIDES. 

worms as to be distended and to have acquired a considerably 
larger size than natural, while at the same time it was hard and 
elastic. The jejunum, ileum, and caecum were filled, so that it 
seemed as though the worms must have been pushed in by force. 
They were found also, but in smaller quantity, in the colon. Dr. 
Condie (Loc. cit. p. 2:30), states that he has known one hundred 
and twenty lumbricoides to be voided in a single day, by a child 
five years old. It ought, however, to be remarked, that the in- 
stances in which such large numbers are met with are altogether 
exceptional, especially in our northern states. I have never 
myself known more than six, eight, or ten to be expelled, within 
a few days' time, and very generally there have not been more 
than three, four or five. 

Anatomical lesions. — When the number of lumbricoides is 
small, the mucous membrane has been found in a state of per- 
fect health, while, on the contrary, when they were numerous, 
and especially when collected together into knots, the membrane 
has been observed to present a fine injection like that which exists 
in erythematous enteritis ; in some very rare instances on record, 
in which the quantity of worms has been very great, the mucous 
membrane has been found deeply injected, thickened, granulated, 
and in a smaller proportion of cases softened, and even eroded. 
Not unfrequently the intestine presents all the characters of well- 
marked enteritis, or entero-colitis, though the number of worms 
may be very small. In such cases it is reasonable to suppose that 
the inflammatory affection has been an accidental complication of 
the verminous disorder. 

Much discussion has arisen in regard to the manner in which 
"perforation of the intestine as an accompaniment of worms takes 
place. It is necessary to suppose, in subjects in whom worms are 
found in the peritoneal cavity, or in abscesses formed in the 
abdominal parietes, that perforation of the bowel has taken place, 
and yet in some instances no trace of the opening is left, no in- 
flammation of the serous membrane is met with, nor has there 
been any escape of the contents of the digestive canal info the 
abdominal cavity. In others, however, and much the most 
numerous cases, it is evident from the anatomical appearances 



ANATOMICAL LESIONS. 551 

presented, that the perforation has taken place in consequence of 
previous ulceration of the coats of the bowel, and that the worms 
have escaped with the other contents of the intestine. It is in 
regard to the former class, therefore, that discussion has prin- 
cipally taken place ; some asserting that the parasite itself makes 
the opening, by an active process, while others deny the possi- 
bility of this occurrence, and maintain a previous ulceration or 
softening in all cases. Amongst those who advocate the possi- 
bility of perforation independent of previous change in the intes- 
tinal coats by disease, are MM. Mondiere and Charcelay, the 
former of whom has examined the subject with a great deal of 
care, quoted by Rilliet and Barthez ; Rilliet and Barthez themselves ; 
the authors of the Bibliot. du Med. Prat., and M. Guersent ; 
while amongst those opposed to this opinion may be cited, MM. 
Cruveilhier, Barrier, Dr. Arthur Farre, who greatly doubts the 
possibility of the accident, and Dr. Condie. I confess myself 
inclined to believe from facts stated by different authors, and 
from the history of two cases which occurred to M. Guersent 
in 1841, at the Children's Hospital of Paris, (Lac. cit. p. 680,) 
that worms may in some instances cause a perforation inde- 
pendently of previous disease of the coats of the intestines. In 
one of these, two lumbrici were found engaged in an opening in 
the appendix vermiformis, half the bodies of the animals being in 
the appendix, and half in the peritoneal sac ; while in the other, 
an opening of the same kind as in the previous case was found in 
the appendix, and though the three worms which were found lying 
in the abdominal cavity might have escaped through an ulcerated 
perforation of the colon, it is not the less true that the opening in 
the appendix presented the same characters exactly as in the first 
case, in which the animals were, as the author remarks, " taken 
in the act." In both instances, the perforation of the appendage 
was at the extremity of that canal, and in the form of a narrow open- 
ing of a conical shape ; the membranes were smooth, thinned, and 
the edges of the orifice sloped off from within outwards ; no trace 
of anterior ulceration was perceptible. 

In regard to the verminous abscesses already referred to, I shall 
make but iew remarks, referring the reader to more extensive 



552 ASCARIS LUMBRICOIDES. 

treatises for fuller information. These abscesses have been in very- 
rare instances met with in the pharynx and nasal passages, but 
much more frequently they exist in the abdomen. The latter may 
be of two kinds, stercoraceous and non-stercoraceous. In the for- 
mer, the abscess which forms upon some portion of the walls of the 
abdomen, gives issue not only to the worm or worms and pus, but 
also to fcecal and even alimentary substances, and leaves behind a 
fistula connecting with the cavity of the intestine which may cica- 
trize after a short time, or remain open during life. In the other 
form of abscess, the opening through the coats of the intestine has 
been closed immediately after the passage of the worm, so that the 
abscess gives issue only to the animal and pus, after which it 
heals up without giving rise to a fistula. 

The verminous abscesses are said to be found generally about 
the inguinal and umbilical regions ; to occur most frequently be- 
tween the ages of seven and fourteen years, and not to be, as a 
general rule, very dangerous to life. 

Symptoms indicative of the presence of worms. — I believe it is 
nearly universally acknowledged by later writers, that there is no 
single symptom, nor group of symptoms, other than the expulsion 
of the worms, and their detection, which indicate with certainty 
their existence in the digestive tube. This is the expressed opinion, 
amongst others, of MM. Guersent, Rilliet and Barthez, Barrier, and 
Valleix, and Drs. Eberle and Condie, and it is also the opinion 
which I have myself been led to form from some experience 
amongst children. 

Another point worthy of remark, is, that even though one or 
several worms may have been expelled, it is not always fair to 
conclude that the symptoms under which the child labours, are the 
result of the presence of others of these animals, as there may be 
no more in the bowels, or they may be so few in number as not 
to produce injurious effects ; while, on the contrary, various dis- 
orders of the digestive tube, as chronic indigestion and simple diar- 
rhoea, and inflammatory diseases of the gastro-intestinal mucous 
membrane, may and do exist simultaneously with, and yet inde- 
pendently of, the presence of these parasites. 

The symptoms generally enumerated as indicative of the pre- 



SYMPTOMS. 553 

sence of worms are the following. The child presents various signs 
of disturbed health. The stomach is more or less deranged, as shown 
by furred tongue, eructations, variable appetite, which is sometimes 
diminished, and sometimes increased, thirst, acid or heavy breath, 
and nausea. The abdomen may be enlarged or retracted, generally 
the former, and is often more or less hard and painful to the touch ; 
the condition of the bowels varies in different cases, as they are 
sometimes costive, and sometimes affected with diarrhoea. According 
to M. Guersent, the stools often contain glairy substances, and are 
sometimes streaked with blood and of a yellowish-green colour ; 
the patient often suffers from colics, which may be either dull or 
acute, though more generally the latter, and are generally felt at the 
umbilical region. Children affected with lumbricoides are said to 
present a peculiar physiognomy ; the face is usually paler than 
natural, and sometimes has a leaden tint; the eyes are surrounded 
by bluish rings, and have at the same time a dull and languid expres- 
sion ; the inferior eyelids are often swelled and puffy ; the sclerotic 
coat of the eye assumes a bilious tint ; the nostrils are said to be some- 
times swelled, and the child complains much of irritation and itching 
of those parts, and is constantly picking at them with the fingers. 
In some instances epistaxis takes place. The child is generally pale 
and thin, indolent and languid, or irritable and unhappy. The 
sleep is almost always disturbed. This indeed, is, it seems to me, 
one of the most important signs both of worms and of chronic 
functional disorders of the stomach and bowels. The nights are 
almost always restless, the patient either waking often and wanting 
to drink, or waking in fright and alarm from dreams, or else it 
is constantly tossing and turning in its sleep, and moaning or 
grinding the teeth. 

Other symptoms mentioned by different observers, and by some 
very much depended upon, are acceleration with irregularity of the 
pulse, and dilatation, especially unequal dilatation of the pupils. I 
may cite also strabismus, and occasional cough. 

In children in whom the number of lumbricoides is very large, 
the constitution suffers to a dangerous degree. The symptoms above 
enumerated are very marked, and at the same time the child is 
very pale or sallow, emaciated, weak and without appetite; the ab- 

47 



554 ASCARIS LUMBRICOIDES- 

domen is hard and tumid ; the nervous symptoms are severe, and 
some of the symptoms which I shall describe presently, under the 
head of disorders occasioned by worms, are also observed. 

It should be remarked, however, again, that all or any of the 
symptoms just described may exist independently of the presence 
of worms, the only certain sign of which is their expulsion from 
the patient. 

Morbid effects occasio?ied by worms. — MM. Riiliet and Barthez 
divide the accidents or effects produced by the existence of lumbri- 
coides into two groups ; those which result from the mechanical 
influence of the entozoa, as their accumulation or displacement ; 
and those which appear to be the consequences of a purely sym- 
pathetic action on the different systems of the body, and particu- 
larly the nervous system. 

Mechanical effects. — Under this head are included perforation 
and hemorrhage of the intestine, enteritis, and abscesses, and the 
symptoms determined by the displacement or migration of the 
worms into the ductus communis choledochus, liver, or air- 
passages. 

Of perforation and abscesses I have already treated under the 
head of anatomical lesions. Hemorrhage is a very rare event, 
but occurred in one instance cited by Riiliet and Barthez, and 
Guersent, from M. Charcelay, in consequence of the rupture of an 
arteriole in a small rounded ulceration in the duodenum, apparently 
occasioned by the presence of a large number of lumbrici. Enteritis, 
as an effect of the presence of worms, has also been referred to under 
the head of the anatomical lesions. In many instances, it is no doubt 
a mere accidental complication, in no way connected with the pre- 
sence of entozoa ; probably this is true of a large majority of the 
cases. When, however, the number of the parasites is very great, 
and particularly when they are collected into large and firm knots or 
bundles, they may, no doubt, occasion by their mechanical irrita- 
tion, inflammation, thickening, softening, and even destruction of the 
mucous tissue, as in cases cited by M. Guersent, from MM. Breton- 
neau and Charcelay, and in one which occurred to himself. It should 
be remarked, however, that the cases on record, in which ulcerations 
evidently depended upon the presence of worms, are, so to speak, 



SYMPTOMS. 555 

infinitely few in comparison with those in which no such alteration 
existed, or in which it was evidently independent of any influence 
exerted by the worms. 

Effects caused by the displace merit or migration of worms.- — 
Lumbricoides have been found, as we have already seen, in the 
walls of the abdomen, giving rise to abscesses. They have been 
discovered also in the ductus communis choledochus, in the gall- 
bladder, hepatic ducts, in the substance of the liver forming ab- 
scesses, and in the pancreatic canal. The symptoms occasioned 
by the latter class of cases are very obscure. In one instance, M. 
Guersent supposed that an attack of convulsions depended upon 
the presence of worms in the common duct. 

More numerous examples are on record, in which violent 
dyspnoea and cough or fatal asphyxia have occurred in conse- 
quence of the pressure of lumbricoides, which had passed into the 
oesophagus, or from their introduction into the larynx, trachea, or 
bronchia. The symptoms occasioned by these accidents are a 
sudden attack of dyspnoea, anxiety, agitation, threatened suffoca- 
tion, dry, spasmodic cough, acute, painful cries, pain in the larynx 
or trachea, and unless relief be obtained in a few hours, death. 
This kind of attack may depend on the rising of a worm or bundle 
of worms into the oesophagus, causing pressure on the larynx and 
trachea, as in a case reported by M. Tonnelle, in which the symp- 
toms disappeared after the expulsion of a large number of worms. 
I met with an instance of this nature myself. It occurred in a 
boy fifteen years old, presenting every mark of strong and vigorous 
health, but who for three or four weeks before I was consulted in 
regard to him, had been subject to sudden and apparently causeless 
attacks of suffocation, which seized him without the least warning. 
When the attack came on, he would for some instants cease to 
breathe, or breathe with much difficulty. He always seemed to 
suffer from the greatest anxiety ; the countenance became altered 
and distressed; he was unable to speak, but made signs for water, 
and when able to swallow a mouthful, which was always exceed- 
ingly difficult, was at once relieved. His mother told me that he 
always appeared to be in the greatest distress, so that on several 
occasions, she feared for his life. Striking him violently on the 



556 ASCARIS LUMBRIC0IDE9. 

back, which she always did, when she was present, sometimes re- 
lieved him, but generally the difficulty continued until he could 
swallow a little fluid of some kind. These attacks were unattended 
at the time by cough, nor was there the least sign of disorder of 
the respiratory system in the intervals between them. Suspecting 
that the difficulty must depend on the rising of a worm or worms 
into the oesophagus, or upon sympathetic irritation from the pre- 
sence of those parasites in the stomach, and learning that he had 
been troubled with worms some years previously, I gave him worm- 
seed oil, which caused the expulsion of a few large lumbricoides, 
after which he had no return of the symptoms. 

The attacks of dyspnoea may depend also, as already stated, on 
the introduction of worms into the air-passages. Under these cir- 
cumstances death is very apt to be the result. In one instance, 
however, reported by M. Arronssohn, after the difficulty had lasted 
two hours, the patient, a little girl eight years old, after violent 
efforts of coughing, threw up a living lumbricus. 

We have next to consider the sympathetic effects, and particu- 
larly the nervous symptoms, occasioned by worms. We may 
include amongst the nervous symptoms produced by worms the 
headache, languor, irritability, restless and disturbed sleep, and 
grinding of the teeth, so frequently observed. These, however, 
are of but slight importance in comparison with certain other dis- 
orders of the nervous system, which do undoubtedly occur some- 
times, though I should suppose very rarely, in proportion to the 
whole number of subjects affected with the parasites. The disorders 
to which I allude are partial or general convulsions, chorea, hys- 
teria, catalepsy, and epilepsy, which are the most frequent, though, 
as so often stated already, extremely rare in comparison with the 
number of cases in which the presence of the worms produces no 
such effects. Other disorders cited by the authors of the Bib. du 
Med. Prat., with cases to prove their authenticity, are insanity, 
paralysis, coma, palpitations, strabismus, cough, hyperesthesia of 
the skin, amaurosis, and aphonia. 

Diagnosis. — It has already been stated that there are no 
certain signs of the presence of worms in an individual except 
their expulsion. The symptoms which have seemed to me most 



DIAGNOSIS PROGNOSIS. 557 

strongly to indicate their presence are a chronic disordered state 
of the digestive apparatus, producing irregular appetite, which is 
sometimes good and at others bad ; slight emaciation ; paleness 
or unhealthy tint of the complexion ; languid expression of the 
face ; some irritability of the temper or a want of the gayety and 
activity of disposition natural to childhood ; picking at the nose ; 
often some tumidity of the abdomen, which may be at the same 
time either hard or merely tympanitic ; and what seems to me 
more important than any that I have named, very restless and 
broken sleep at night, with frequent grinding of the teeth. 

M. Valleix remarks that in a case presenting nervous symptoms 
simulating disease of the brain, we may suspect the existence of 
worms, if we learn upon inquiry that symptoms of marked intes- 
tinal disorder, the various signs cited above as indicative of the pre- 
sence of worms, and different derangements of digestion, had pre- 
ceded for some time the appearance of the nervous symptoms ; 
chiefly for the reason that in most diseases of the brain, the digestive 
tube is at the invasion in a state of integrity, with the exception of 
sympathetic vomiting. If we can learn, upon inquiry, that the child 
has discharged worms on some previous occasion, the probability 
of the dependence of the symptoms upon them becomes still 
stronger. 

It is sometimes difficult to determine positively whether cer- 
tain substances discharged at stool are fragments of worms, or 
whether they are portions of imperfectly digested aliment, or 
foreign bodies. The things which most resemble lumbricoides, 
are the remains of tendons, ligaments, vessels, fibres of plants, etc. 
To make the distinction with certainty, the doubtful substance 
ought to be placed in water, so that it may be thoroughly cleansed, 
after which it must be carefullv examined as to its structure, arrange- 
ment, consistence, etc., with the eye, and with the microscope, if 
necessary. M. Guersent has suggested a very easy method of 
ascertaining wiiether the substance be animal or vegetable, which 
is to subject it to heat, after it has been carefully washed, when 
the odour will at once inform us of its real nature. 

Prognosis. — It is no doubt a very rare event, at least in the 

northern parts of our country, for life to be endangered by the pre- 

47* 



558 ASCARIS LUMBRICOIDES. 

sence of worms. I have never, myself, met with an instance in 
which the general health was more than moderately disturbed by 
this cause. That verminous affections are sometimes, however, 
dangerous to life in this city, is shown by three cases related by 
Dr. Dewees, in which very severe and threatening symptoms were 
instantly relieved upon the expulsion of lumbrici after the exhibition 
of vermifuges. 

Worms become dangerous to life when they migrate from their 
original seat to neighbouring and important organs, particularly 
the air-passages and liver. The prognosis is unfavourable also 
when they accumulate in very large numbers, and give rise to the 
different nervous symptoms above described. 

Treatment. — Before commencing my remarks upon the parti- 
cular remedies employed for the destruction and expulsion of 
worms from the alimentary canal, I would call the attention of the 
reader to the fact that most of the recognised anthelmintics are 
more or less irritating to the gastro-intestinal mucous membrane, 
and some of them to the nervous system also, producing in over 
doses severe and even dangerous nervous symptoms. It is 
evident, therefore, that remedies of this class ought not to be exhi- 
bited unless they are manifestly called for, and not at all when 
symptoms of severe gastro-intestinal irritation, and particularly of 
inflammation, are present, unless there be the very strongest rea- 
sons for supposing that those symptoms depend upon accumula- 
tions of worms. I am quite sure that I have, in a considerable 
number of instances, met with children whose digestive organs had 
been injured, in whom slight functional derangement had been 
converted into severe indigestion, and even inflammatory disorder, 
by the too frequent or long-continued use, or the administration in 
excessive quantities of different vermifuges, and of various quack 
nostrums, which are sold to an amazing extent in this city, at least, 
and no doubt all over the country. 

As the diagnosis of worms is always doubtful, it is best never to 
risk the administration of any of the irritating vermifuges, unless 
convinced, by the previous expulsion of worms, that they are almost 
certainly present; and, indeed, I myself rarely give any other re- 
medy than small quantities of the worm&eed oil in slight, and espe- 



TREATMENT. 559 

cially in doubtful cases, unless this has already been tried and 
failed. From my own experience I believe that this remedy is all 
sufficient iu a large majority of the cases that occur in this city, as 
these are almost always of a mild character, and as it not only 
produces the expulsion of the parasites when they exist, but also 
acts beneficially upon the form of digestive irritation which simu- 
lates so closely the symptoms produced by worms. I am per- 
suaded, indeed, that of all the cases that have come under my 
notice, in which it seemed probable that worms might be present, 
none were expelled in nearly half, and yet the signs of disturbed 
health have passed away under the use of the remedy. The oil of 
wormseed may be given in dcses of four drops to children of two 
years of age, and of six or eight to those above that age, three 
times a day for three days, to be followed on the morning of the 
fourth day by a moderately active, but not irritating cathartic dose, 
the best of which is castor oil or syrup of rhubarb. The objection 
to the remedy is its nauseous taste and smell ; these, however, 
may be partially concealed by making it into a mixture with yelk 
of egg, powdered gum, and syrup of ginger. Some children take 
it very well dropped upon a lump of white sugar, while others take 
it best mixed with common brown sugar. If one course of the oil, 
as it is called, fail to relieve the symptoms, another should be ad- 
ministered. It ought to be recollected that when given in large 
doses, the wormseed oil is irritating to the digestive mucous mem- 
brane, and produces dangerous nervous symptoms. 1 know of one 
case in which a girl six or seven years of age was made ex- 
ceedingly ill, and suffered for years afterwards from the effects of 
a teaspoonful of the oil given by mistake. 

The wormseed may be given also in powder, in the dose of from 
twenty to forty grains. 

The remedies most frequently employed in this country besides 
the wormseed, are pink-root or spigelia, oil of turpentine, calomel, 
and the bristles of cowhage. 

I believe that the pink-root is more depended upon amongst us 
than any other single remedy. It is given either in substance or 
infusion. The dose of the powder is from ten to twenty grains 
for a child three or four years old, to be repeated every morning 



560 ASCARIS LUMBRICOIDES. 






and evening for several days, and followed by an active cathartic. 
It is seldom used, however, in this way, but almost always in in- 
fusion. I believe that the best and safest mode of administering 
it is in combination with cathartic substances. Thus, half an 
ounce each of pink-root and senna, may be infused for a few hours 
in a pint of boiling water, and a tablespoonful given two or three 
times a day, to children two or three years old, for three, four, or 
five days, when it should be suspended for a time, and resumed, if 
necessary. A preparation much used in this city under the title 
of worm tea, and which I have given myself with very good suc- 
cess, consists of the spigelia mixed with senna, manna, and savine, 
in different proportions, made into an infusion and sweetened with 
brown sugar. Dr. G. B. Wood {Bract, of Med., vol. i, p. 626), 
recommends the following formula : R. — Sennas, Spigelias, aa 3ss ; 
Magnesias Sulphat. 3ii; Mannas 3i; Fceniculi 3ii; Aquas fervent Oj. 
These are to be macerated for two hours in a covered vessel, and 
a tablespoonful given to a child two years old once or twice a day, 
or every other day, so as to procure two or three evacuations in 
the twenty-four hours. The remedy is continued for a few days, 
or for one or two weeks, if necessary, and if it do not debilitate 
the child. 

The spirits of turpentine are highly recommended as an effi- 
cient remedy for worms by several authorities, and particularly by 
Dr. Joseph Klapp and Dr. Condie of this city. Dr. Condie states 
that it is the article from which he has derived the most decidedly 
beneficial effects, and remarks that it may be given when there 
exists considerable irritation of the alimentary canal, or even sub- 
acute inflammation, without any fear of its increasing either. He 
gives the rectified spirits in sweetened milk, in molasses, or in the 
following mixture : r>. — Mucil. G. Acacias 3ii ; Sacch. alb. 3x ; 
Spir. iEther. nitr. 3iii; Spir. Terebenth. rec. 3iii; Magnes. Calcinat. 
Bi ,* Aquas Menthas 3i. — M. Of this mixture a dessert spoonful is 
given every three hours. I have used the spirits of turpentine but 
once, on account of its extremely disagreeable taste, having up to 
this time always succeeded perfectly well with the wormseed oil, 
or infusion of pink-root with cathartics. 

Calomel is also highly thought of by many persons as a vermi- 






TREATMENT. 561 

fuge, and, no doubt, when used in combination with, or followed 
by cathartics, or given in full purgative doses, it is very effectual. 
I can only repeat what I have already said on several occasions, 
that it is a remedy which, from the powerful influence it exerts 
upon the constitution, ought not to be given except when really 
called for ; and as we can almost always succeed in verminous 
affections by milder drugs, I see no occasion for resorting to this, 
except in exceptional cases. When used it is given alone in con- 
siderable doses, and followed by some cathartic, or in combination 
with rhubarb and jalap, or jalap and scammony. 

The bristles or down of cowhage are also used by some practi- 
tioners, and no doubt sometimes with success. I have never used 
them, and can give no opinion, therefore, from personal experi- 
ence, as to their efficacy. They are administered by making them 
into an electuary with honey, syrup, or molasses, a teaspoonful of 
which is given every morning for three days, and then followed 
by an active cathartic. 

The following electuary, recommended by Bremser, is very 
much employed in Europe, and is highly spoken of by Dr. Eberle : 
R. — Semin. Santonicse (semen-contra of the French writers), Se- 
min. Tanaceti rude contus., aa 3ss ; Valerian, pulv. 3ii ; Jalapse 
pulv. 3iss — ii ; Potass. Sulphat. 3iss — ii ; Oxymel. Scillse, q. s., ut 
ft. electuarium. A teaspoonful of this is given morning and evening 
for three or four days, when the dejections generally become more 
copious and liquid. If it does not produce this effect, Bremser ad- 
vises that the dose be increased. Dr. Eberle gave it for six or 
seven days, and says it does far less good when it produces frequent 
and watery evacuations, than when it causes only three or four 
consistent stools a day. This preparation has a very disagreeable 
taste, and children sometimes refuse to take it on that account. 
When this is the case it may be made into pills. 

Rilliet and Barthez recommend the following syrup, which was 
proposed and highly thought of by M. Cruveilhier : R. — Follicul. 
Sennse, Rhei, Semin. Santonic, Artem. Abrotan., Helminthocort., 
Tanaceti, Artemis. Pontic, aa 3i. To be infused in half a pint of 
cold water, strained, and made into a syrup with sugar, of which 
a tablespoonful is to be given every morning for three days. M. 
Cruveilhier states that this syrup has been very successful in his 



562 ASCARIS LUMBRICOIDES. 

hands. The empyreumatic oil of Chabert is also highly spoken of 
by some European authorities. It is made by mixing one part of the 
empyreumatic oil or fetid spirits of hartshorn, with three parts of 
spirits of turpentine, and suffering them to digest for four days. The 
mixture is then put into a glass retort, and distilled in a sand-bath 
until three-fourths of the whole have passed over into the receiver. 
The product should be kept in small and tightly-closed phials. 
The dose is about fifteen or twenty drops three or four times a day, 
for children between two and seven years old. This is recom- 
mended highly by Bremser and other authorities. The great 
objection to it is its exceedingly nauseous taste. Dr. Eberle 
speaks in very favourable terms of a strong decoction of helmin- 
thocorlon or Corsican moss, which he has found " not only valu- 
able as a vermifuge, but particularly so, as a corrective of that 
deranged and debilitated condition of the alimentary canal favour- 
ing the production of worms." An ounce of helminthocorton, 
with a drachm of valerian, are to be boiled in a pint of water 
down to a gill, and a teaspoonful of the decoction given morning, 
noon, and evening. It is particularly beneficial in cases attended 
with the usual symptoms of worms, connected with want of appe- 
tite and mucous diarrhoea, and arising from debility of the diges- 
tive organs and vitiated condition of the intestinal secretions. 

In all cases of deranged health supposed, either by the nature 
of the symptoms, or proved by the previous expulsion of worms, 
to depend on the presence of those animals in the alimentary canal, 
it is exceedingly important to attend to the hygienic treatment of 
the child, and in some instances to administer tonics and stimulants. 
In not a few cases that have come under my notice, in which 
many of the symptoms supposed to indicate the presence of worms 
have been extremely well marked, I have succeeded in removing 
them all without a resort to any vermifuge, by the treatment 
proper for the chronic indigestion or dyspepsia of children. The 
method of treatment to be employed in such cases has already 
been laid down in the article on indigestion, to which the reader 
is referred for full information. It should consist chiefly in strict 
attention to exercise and diet, and in the use of tonics, as quinine 
and iron, and small quantities of fine port wine. 



TREATMENT. 563 

Whenever any complication exists in connexion with worms, 
the treatment must be modified according to the nature of the 
complication. If it consist in inflammation of any part of the 
digestive tube, the inflammation ought to be attended to first, and 
the verminous disorder for the time neglected. If the inflamma- 
tion be very slight, or, if the symptoms indicate only severe 
irritation rather than positive inflammatory action, we may exhibit 
the milder and least injurious vermifuges, as very small doses of 
wormseed oil, which I have never known to do harm, the decoc- 
tion of helminthocorton and valerian, recommended by Dr. Eberle, 
or according to Dr. Condie, the spirits of turpentine. If the ver- 
minous affection coexist with any of the acute local inflammations 
of the thorax, the former ought to be, as a general rule, neglected, 
until the latter has been relieved by appropriate treatment. In 
doubtful cases, in which it is impossible to ascertain with certainty 
whether the symptoms depend on worms, or upon a simple dys- 
peptic condition of the digestive organs, it is most prudent to give 
only the simplest and least irritating vermifuges, to regulate the 
hygienic conditions of the patient, and afterwards to resort to 
tonics, if necessary. 

Various writers, and particularly M. Guersent, advise that we 
should forbid, in verminous cases, the use of relaxing food, espe- 
cially of milk preparations, fruits, and of fatty and farinaceous 
substances ; and that, after the expulsion of the worms, we should 
direct a tonic and strengthening regimen. The diet should con- 
sist of boiled and roasted meats, of wine, and of bitters. The 
author just quoted, states that a change of food alone will often 
suffice to procure the expulsion of the worms. He says (Diet, de 
Med. t. xxx, p. 689), " I have met with children who had been 
tormented with ascarides lumbricoides while residing in the 
country and living upon milk and fruits, and who, upon being 
brought to the city, and put upon the use of broths and soups, 
passed considerable quantities of worms, and after that got entirely 
rid of them." 



564 ASCARIS VERMICULARIS. 

ARTICLE II. 

ASCARIS VERMICULARIS. 

The description of this worm has already been given at 
page 544. 

Seat. — The ascaris vermicularis is found almost exclusively in 
the large intestine, and in a large majority of the cases is con- 
fined to the rectum. It is said to have been found in the vagina 
in the female, having no doubt passed from the rectum into that 
canal. 

The causes of this worm are not at all understood. 

Symptoms, — The characteristic, and often the only symptom 
indicative of their presence, is violent itching about the anus, 
which is sometimes almost insupportable, and which is generally 
most troublesome and most apt to occur at night, when the child 
is in bed. In some instances they give rise to acute and violent 
pains in the region of the anus, and sometimes to tenesmus and 
mucous or bloody stools. When the last named severe symptoms 
exist, the worms may occasion dangerous nervous disorders, and 
even give rise to general convulsions. The worms not unfre- 
quently escape from the rectum and are found upon the bed- 
clothes, or upon the clothes which the child has worn through the 
day. Sometimes they are discharged in considerable numbers, 
and are found in that case, either mixed with the faeces, or with 
mucus, or collected into balls or knots. 

The diagnosis of the seat- worm, like that of the lumbricoides, 
cannot be regarded as positive, unless some have been expelled, 
or unless they can be seen by examination of the rectum. This 
can generally be done when they are present in any number, by 
pressing the nates apart so as to open the anus, and bring the folds 
of the mucous coats of the bowel into view. The only other 
symptom which indicates their presence with any certainty, is the 
existence of severe itching about the anus, not to be explained upon 
any more reasonable supposition. 

Prognosis. — These worms do not, as a general rule, produce the 



TREATMENT. 565 

same disturbances of the general health, as lumbricoides, and in 
not a few instances, are entirely innocuous, with the exception 
of the pain and inconvenience which they occasion. 

They are, however, exceedingly troublesome, because of the 
difficulty of removing them entirely by any treatment. No matter 
how many are discharged, some almost always remain concealed 
in the folds of the mucous membrane, and as they are propagated 
with great rapidity, the same train of symptoms is very apt to 
return soon after they may have seemingly been dislodged. 

Treatment. — It has been found by long experience that the 
common vermifuges given by the mouth, exert much less influence 
in the expulsion of these worms than of the lumbricoides. For 
this reason enemata are generally resorted to in the treatment in- 
stead of remedies given per orem. Dr. Dewees, however, recom- 
mends the elixir proprietatis (tinct. aloes et myrrhse), in small and 
often-repeated doses, continued for some time, and followed by 
enemata of lime-water, camphor, or aloes. He gave twenty drops 
of the elixir three times a day, in a little sweetened milk, to chil- 
dren from two to four years old, and thirty drops to those between 
five and seven years. 

The plan I have generally resorted to has been to give small 
doses of the wormseed oil, as directed in the article on lumbri- 
coides, and to direct an injection of from four to six grains of 
powdered aloes, suspended in a gill of warm milk, for children 
four years old, to be repeated once in three, four, or five days, 
according to the necessity of the case. 

Lime-water by injection is recommended by several different 
authorities. It may be given of its ordinary strength, or mixed 
with an equal quantity of warm milk, or flaxseed mucilage. Other 
enemata recommended are spirits of turpentine in milk, a tea- 
spoonful of the former to a gill of the latter ; decoction of helmin- 
thocorton ; an injection made by infusing two drachms of fresh 
garlic-cloves in three ounces and a half of boiling water, and 
adding to the infusion, after it has been poured off, a scruple 
of assafcetida rubbed up with the yelk of an egg ; a solution of 
from six to twelve grains of sulphuret of potassium in half a pint 
of water ; injections of sweet oil, or of lard beaten up with water 

48 



566 ASCARIS VERMICULARIS. 

until it becomes fluid, and even of cold water. The three last- 
mentioned substances have the advantage of calming the itching and 
irritation of the rectum almost immediately. Again, it has been 
recommended to pass a bougie smeared with mercurial ointment 
into the rectum. I should much prefer the method of using this 
ointment which succeeded in the hands of M. Cruveilhier in a 
very severe case. This was to place a little of the ointment on 
the anus, which relieved the patient entirely after a few days. M. 
Valleix states that he has obtained the same results by causing 
the anus to be anointed with the following preparation, a small 
quantity of which was introduced at the same time into the inferior 
extremity of the intestine : R. — Hydrarg. Chlor. Mitis Biv ; 
Axung. 3vi. — M. 

Dr. Wood states that a dose of sulphur taken every morning 
before breakfast has been found very useful. 

The diet and general health ought always to be strictly inquired 
after, and attended to by the physician. For information upon 
these points the reader is referred to the remarks upon hygienic 
treatment in the last article. 



INDEX 



A. 

Abscesses in pneumonia, 78. 

Angina maligna, see pseudo-membranous pharyngitis. 

Angina, pseudo-membranous, see pseudo-membranous pharyngitis. 

Angina, simple or erythematous, see simple pharyngitis. 

Apoplexy, cerebral and meningeal, see cerebral hemorrhage. 

Aphthoe, frequency, 154; frequency and forms, 155 ; causes, ibid. ; symptoms, 
ibid. ; duration, ibid. ; diagnosis and prognosis, 156; treatment, ibid. 

Arachnitis, see meningitis. 

Ascaris lumbricoides, 548 ; description, 543 ; causes, 548 ; seat, 549 ; num- 
ber, ibid. ; anatomical lesions, 550; symptoms indicating presence of, 
552 ; mechanical effects of, 554 ; effects caused by migration, 555 ; sym- 
pathetic effects of, 556; diagnosis, ibid.; prognosis, 557; treatment, 558. 

Ascaris vermicularis, 564 ; description, 544 ; seat, 564 ; symptoms, ibid. ; 
diagnosis and prognosis, ibid. ; treatment, 565. 

Asthma, Kopp's or thymic, see laryngismus stridulus. 

Atrophia ablactatorum, see entero-colitis. 

B. 

Belladonna as a preventive of scarlet fever, 491. 

Bowels, inflammation of, 254. 

Brain, congestion of, see cerebral congestion. 

Brain, inflammation of, see encephalitis, 323. 

Bronchitis, 105; frequency, ibid.; forms, 106; predisposing causes, ibid.; 
exciting causes, 107; anatomical lesions, ibid. ; symptoms of acute simple 
form, 108; of acute suffocative form, 109 ; of subacute and chronic form, 



568 INDEX. 

110; physical signs in, ibid.; diagnosis, 114; prognosis, ibid. ; treat- 
ment, 115. 
Broncho-pneumonia, see pneumonia. 



Cancrum oris, see ulcerative stomatitis and gangrene of the mouth. 

Carpo-pedal spasms, see laryngismus stridulus, and contraction with rigidity. 

Catarrh, see bronchitis. 

Catarrhal-fever, see bronchitis and lobular pneumonia. 

Catarrh, congestive, see acute suffocative bronchitis. 

Cerebral congestion, 368 ; rarely occurs in children, ibid. ; symptoms, 371; 
treatment, 373. 

Cerebral hemorrhage, 373; frequency and forms, 374; causes, 375; ana- 
tomical lesions of cerebral apoplexy, 376, of meningeal apoplexy, 377 
symptoms of cerebral hemorrhage, 379, of meningeal hemorrhage, 381 
duration of cerebral and meningeal hemorrhage, 382 ; diagnosis, 383 
prognosis, ibid. ; treatment, ibid. 

Cholera infantum, 288 ; frequency, ibid. ; causes, 289 ; anatomical lesions, 
292; nature of, 295; symptoms, 298; duration, 303; diagnosis and 
prognosis, ibid. ; treatment, 305. 

Chorea, 433 ; causes, 434 ; anatomical lesions, ibid. ; symptoms, ibid. ; causes, 
437 ; duration, 438 ; nature, ibid. ; diagnosis and prognosis, ibid. ; treat- 
ment, 439. 

Colitis, see entero-colitis and dysentery. 

Colon, inflammation of, see entero-colitis and dysentery. 

Congestion, cerebral, see cerebral congestion. 

Contraction with rigidity, 428 ; frequency, ibid. ; causes, 429 ; nature, ibid. ; 
symptoms, 430 ; course and duration, 431 ; diagnosis, ibid. ; prognosis, 
432 ; treatment, ibid. 

Contracture, see contraction with rigidity. 

Convulsions, general, see eclampsia. 

Coryza, 25 ; forms, ibid. ; frequency, 26 ; causes, ibid. ; anatomical lesions, 
27; symptoms, ibid. ; duration, 28; prognosis, 29; treatment, ibid.; 
case, 30. 

Croup, true, 32 ; false or spasmodic, 52. 



INDEX. 569 



Cynanche tonsillaris, see simple pharyngitis. 
Cynanche trachealis, see croup. 



D. 



Diarrhoea, inflammatory, 254. 

Diarrhoea, simple, 222 ; see also entero -colitis; frequency, 233 ; causes, ibid, ; 

symptoms, 235 ; course and duration, 238 ; diagnosis, ibid. ; prognosis, 

ibid. ; treatment, ibid. 
Digestive organs, diseases of, 153. 
Diphtheritis, see pseudo-membranous pharyngitis. 
Diseases of the nasal passages, 25 ; of the larynx, 31 ; of the lungs and pleura, 

74; of the mouth, 153; of the throat, 197; of the stomach and intestines, 

215 ; of the nervous system, 322. 
Dropsy in scarlet fever, 462. 
Dysentery, 318; causes, 319; anatomical lesions, ibid.; symptoms, ibid.; 

diagnosis and prognosis, 320 ; treatment, ibid. 



E. 



Eclampsia, 386 ; general remarks, ibid. ; divisions, ibid. ; frequency, 387 ; 
predisposing causes, ibid. ; exciting causes, 389 ; symptoms, ibid. ; dura- 
tion, 392 ; nature, 393 ; diagnosis, 395 ; prognosis, 398 ; treatment, 399. 

Encephalitis, 323. 

Enteritis, simple, follicular, and pseudo-membranous, see entero-colitis. 

Entero-colitis, 254; general remarks, ibid.; forms, 255; frequency, 256; 
causes, 257 ; anatomical lesions, 260, of erythematous inflammation, 
262, of follicular inflammation, 263, of softening, 267 ; symptoms of 
acute form, 268, of chronic form, 273 ; diagnosis, 274 ; prognosis, 275 ; 
treatment, ibid. 

Eruptive fevers, 445. 

Erythematous stomatitis, 153; pharyngitis, 197. 

48* 



570 INDEX. 



Fauces, simple inflammation of, see simple pharyngitis; diphtheritic inflam- 

mation of, see pseudo-membranous pharyngitis. 
Fevers, eruptive, 445. 
Follicular enteritis, see entero-colitis. 
Follicular stomatitis, see aphthae. 



G. 



Gangrene of the mouth, 163; frequency, ibid. ; predisposing causes, ibid.; 
exciting causes, 164; anatomical lesions, ibid. ; symptoms, 166; dura- 
tion, 169; complications, ibid. ; diagnosis, 170; prognosis, 171; treat- 
ment, 172. 

Gangrsenopsis, see gangrene of the mouth. 

Gangrenous sore-mouth, 158 and 163. 

Gastritis and softening of the stomach, 244; general remarks, ibid. ; fre- 
quency, 246 ; causes, ibid. ; anatomical lesions, 247; lesions of pseudo- 
membranous form, ibid., of ulcerative form, ibid. ; lesions of inflamma- 
tory softening, 249, of post-mortem softening, 250, of gelatiniform soften- 
ing, ibid. ; symptoms, 251 ; diagnosis and prognosis, 252 ; treatment, ibid. 

Gastro-enteritis, see general remarks on the diseases of the stomach and in- 
testines, 215. 

Gelatinous softening of the stomach, see gastritis. 

General convulsions, see eclampsia. 

Glottis, spasm of, see laryngismus stridulus. 



H. 

Holding breath spells, 417. 

Hooping-cough, 135 ; frequency, 136; causes, ibid. ; stages, ibid. ; symptoms 
of first stage, ibid., of second stage, 137, of third stage, 139; duration, 
ibid. ; complications, ibid, ; diagnosis, 141 ; prognosis, 142 ; nature of, 
143 ; treatment, 144. 



INDEX. 571 

Hydrocephalus, acute, 363 ; see also tubercular meningitis, 323 ; frequency, 
364 ; causes, ibid. ; anatomical lesions, ibid. ; symptoms, 365 ; diagnosis 
ibid. ; prognosis, 366 ; treatment, ibid. 



I. 



Indigestion, 218; forms, ibid.; causes, ibid.; symptoms, 220 ; diagnosis, 224; 
prognosis, 225 ; treatment, ibid. 

Inflammation of the brain, see meningitis ; of the bronchi, see bronchitis ; of 
the colon, see entero-colitis ; of the fauces, see pharyngitis ; of the intes- 
tines, see entero-colitis ; of the lungs, see pneumonia ; of the mouth, see 
erythematous stomatitis ; of the nares, see coryza ; of the pleura, see 
pleurisy ; of the stomach, see gastritis ; of the tonsils, see pharyngitis ; of 
the throat, see pharyngitis. 

Intestinal mucous membrane, softening of, 255. 

Intestines, inflammation of, 254 ; worms in, 543. 



K. 



Kanker of the mouth, see gangrene of the mouth. 
Kopp's asthma, see laryngismus stridulus. 



Laryngismus stridulus, 407 ; frequency, 408 ; predisposing causes, ibid. ; 

nature and exciting causes, 409 ; forms, 415 ; symptoms, ibid. ; duration, 

417 ; diagnosis, 418 ; prognosis, 419 ; treatment, ibid. ; cases, 423. 
Laryngitis, pseudo-membranous, 32; frequency, ibid, ; predisposing and ex- 

citing causes, 33 ; anatomical lesions, 34; symptoms, 35 ; duration, 40 ; 

diagnosis, ibid. ; prognosis, ibid. ; treatment, 41. 
Laryngitis, simple, 64 ; forms, 65 ; predisposing causes, ibid. ; exciting causes, 

ibid. ; anatomical lesions, ibid. ; symptoms, 66 ; duration, 68 ; diagnosis, 

ibid. ; prognosis, 70 ; treatment, 71. 
Laryngitis, spasmodic, 52 ; frequency, ibid. ; predisposing and exciting- causes, 



572 INDEX. 

53 ; anatomical lesions, ibid. ; symptoms, 54 ; duration, 56 ; nature of, 

Hid. ; diagnosis, 58 ; prognosis, 59 ; treatment, 60. 
Larynx, diseases of, 31. 
Lobar pneumonia, see pneumonia. 
Lobular pneumonia, see pneumonia. 
Lungs, inflammation of, 74. 



M. 



Measles, 492 ; frequency, ibid. ; forms, ibid. ; causes, 493 ; symptoms of the 
regular form, ibid. ; irregularities of, 498 ; symptoms of malignant form, 
501; complications and sequelae, 502 ; anatomical lesions, 507 ; diagno. 
sis, 508; prognosis, 509; treatment of the regular form, 511, of the 
complications, 514. 

Meningeal apoplexy, see cerebral hemorrhage. 

Meninges, apoplexy of, see cerebral hemorrhage. 

Meninges, inflammation of, see tubercular and simple meningitis. 

Meningitis, simple, 352 ; frequency, 353 ; causes, ibid. ; anatomical lesions, 
354; symptoms, 355 ; diagnosis, 358 ; prognosis, 360 ; treatment, ibid. 

Meningitis, tubercular, 323 ; confounded with simple hydrocephalus, ibid. ; 
frequency, 325 ; predisposing and exciting causes, 326 ; anatomical 
lesions, 327 ; symptoms, 331 ; duration, 339 ; diagnosis, ibid. ; prognosis, 
341 ; treatment, 343. 

Modified small-pox, 528. 

Morbilli, see measles. 

Mouth, diseases of, 153 ; gangrene of, 163. 

Muguet, see thrush. 



N. 



Nasal passages, diseases of, 25. 

Nervous system, diseases of, 322 ; general remarks, ibid. 



INDEX. 573 



Pertussis, see hooping-cough. 

Pharyngitis, pseudo-membranous, 204 ; frequency, 205 ; causes, ibid. ; ana. 
tomical lesions, 206; symptoms, 207: duration, 209; diagnosis, ibid. ; 
prognosis, ibid.; local treatment, 210; general treatment, 212. 

Pharyngitis, simple or erythematous, 197; frequency, ibid.; causes, ibid.; 
anatomical lesions, ibid. ; symptoms of mild form, 198, of grave form, 
200; diagnosis, 201 ; prognosis, 202 ; treatment, ibid. 

Pleurisy, 119; forms, 120; predisposing and exciting causes, ibid. ; anato- 
mical lesions, ibid. ; symptoms, 122 ; physical signs in, ibid. ; rational 
symptoms, 125; diagnosis, 128; prognosis, 130; treatment, ibid. ; 
case, 133. 

Pneumonia, 74; frequency, ibid. ; forms, 75; predisposing causes, ibid.; ex- 
citing causes, 76 ; anatomical lesions of lobular form of, ibid., of lobular 
form, 79; complications, 81; symptoms, ibid. ; physical signs in, 84; 
diagnosis, 91; prognosis, 95; treatment, 96. 

Putrid sore-throat, see pseudo-membranous angina. 



R. 



Ramollissement of the stomach, see gastritis. 
Revaccination, 539. 

Rigidity with contraction, see contraction with rigidity. 
Rubeola, see measles. 



S. 



Scarlatina, see scarlet fever. 

Scarlet fever, 445 ; frequency, ibid. ; forms, 446 ; causes, 447 ; symptoms of 
the regular form, 449, of the grave anginose form, 453, of the grave cere- 
bral form, 459 ; complications and sequelae, 462 ; anatomical lesions, 
465 ; diagnosis, 467 ; prognosis, 468 ; treatment, of the regular form, 



574 INDEX. 

470, of the grave form, 473, of the angina, 488, of dropsy in, 490 ; pro- 
phylactic treatment, 491. 

Small-pox, 519; frequency, ibid. ; forms, ibid. ; causes, ibid.; symptoms of 
the regular form, 520, of varioloid or modified small- pox, 528 ; anatomical 
lesions, 530 ; diagnosis and prognosis, 432 ; treatment, 533 ; treatment 
of the complications, 535. 

Softening of the stomach, see gastritis. 

Sore mouth of children, see stomatitis. 

Sore throat, putrid, see pseudo-membranous angina. 

Sore throat, simple, see simple angina. 

Spasm of the glottis, see laryngismus stridulus. 

Spasmodic croup, see spasmodic laryngitis. 

Stomach, inflammation of, see gastritis. 

Stomach, softening or ramollissement of, see gastritis. 

Stomatitis, simple or erythematous, 153 ; causes, 154 ; symptoms, ibid. ; treat- 
ment, ibid. 

Stomatitis, ulcerative or ulcero-membranous, 158 ; frequency, ibid. ; predis- 
posing causes, ibid. ; exciting causes, 159 ; symptoms, ibid. ; course and 
duration, 160; diagnosis and prognosis, ibid.; treatment, 161. 

St. Vitus's dance, see chorea. 

Summer complaint, 288. 



Throat, diseases of, 197. 

Thrush, 177; frequency and forms, 178; predisposing causes, ibid.; exciting 

causes, 180; anatomical lesions, ibid.; symptoms, 182; nature, 188; 

diagnosis, 189 ; prognosis, ibid. ; general treatment, 190 ; local treatment, 

195. 
Thymic asthma, see laryngismus stridulus. 
Tonsillitis, see simple and pseudo-membranous angina. 
Tracheotomy, 51. 
Tubercular meningitis, 323. 



INDEX. 575 



u. 

Ulcerative or ulcero-membranous stomatitis, 158. 



Variola, see small-pox. 

Varioloid, 528. 

Verminous affections, see worms. 



W. 



Weaning-brash, see entero-colitis. 

Worms in the alimentary canal, 543 ; general remarks, ibid. ; description, 

frequency, and importance, 546: see also ascaris lumbricoides and 

ascaris vermicularis. 



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